HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 215 FOREST STREET 6/7/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record `� "J o 2021
Form 4 :RTHANDO'VER
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DEP has provided this form for use=by local Boards of Health. Other forms may beused, but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
--1. System Location: Left/Right front of house, Left/Cl Ugbt rear of house)Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � C S
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe):
i
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste ��, n �G�� � ,� / ,� `� ✓���
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
fG L S. / Lowell Waste Water
4�SignAtuful Date
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