HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 805 FOREST STREET 9/7/2021 R
Commonwealth of Massachusetts
ECEIVED
City/Town of Sg 0 7
0001
System Pumping Record TOHTH�EP�EW
Form 4
r•
DEP 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 foram,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 Locationx�Right ont of hous Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fron of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallon
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio re contents were disposed:
�L S Lowell Waste WaterWa O- A. 1-
3�
Signitute I HtuleU Date
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