HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 657 FOREST STREET 6/24/2021 Commonwealth of Massachusetts RECEIVED
City/Town of a 2021
System Pumping Record 3�� 2 VER
Form 4 jOWN OF NORZH S
.V N0l pEPAR
DER has provided this form for use=by local Boards of Health. Other forms may be'used, 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 ORi front of housg Left/Right 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 61i
city/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town state% Zip Cod477
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [t--Y€s E❑ No If yes, was it cleaned? awes'❑ No
5. Condition o System: -�
rl�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G�LJS. Lowell Waste Water
Sign a Haul evDate
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