HomeMy WebLinkAboutSeptic Pumping Slip - 326 FOREST STREET 9/10/2015 : Commonwealth of Massachusetts
_ City/Town of .
System Pumping-Record
Form 4
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 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 . LL /Right(rout of hous , Left/Right rear of house, Left/right side of house, Left/
Right side of buil ing, Left/Right fron o uildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. ` r
Name'
Address(if different from location)
Citylrown ' Stat ip de
Telephone Number ' 4
.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? es ❑ No If yes, was it cleaned? es No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo T*ere contents were disposed:
Lowell Waste Water _
."-ff 10A
Sign a 9t Haule Date
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