HomeMy WebLinkAboutSeptic Pumping Slip - 571 FOREST STREET 8/24/2015 Commonwealth of Massachusetts
City/Town of
C o
System'tem PumpingRecord
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be'used, b*but the
information-must be substantially the tame 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 Locatio Right"rq of hous"eft Right rear of house, Left. right side of house, Left
Right side %ilipng!, Left Right t fCont-o—f building, Left Right rear of building, Under deck
Address
tc)C�M-4
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town Stater Zip Code
Telephone Number
B. Pt;mping Record
1. Date of Pumping Date jq 2. Quantity Pumped:
_i�a
3. Type•of system. ❑ Cesspool(s) M/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ❑ Yes No If Yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System,
( WI k lj�je
V
6.. System Pumped By:
Nell.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
W O- A w k(- 1 5
Sign qt HauleV Date
0=4.doc-08/03 System Pumping Record•Page 1 of I