HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 11/2/2021 Commonwealth of Massachusetts
...W7City/Town of
System Pumping Record
Form 4
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/Right front of house, Left igh rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, eft/Right rear of building, Under deck
Address `�)D-r7
Cityfrown uwJ State Zip Code
2. System Owner.
it
Name
Address(if different from location)
City/Town State Z'
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? ❑ Yes D No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio herentents were disposed:
Lowell Waste Water
ter_
Sign a Haul pift
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