HomeMy WebLinkAboutSeptic Pumping Slip - 64 FOREST STREET 9/8/2015 :_C_\ 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 Location: Left/Right front of house, Left/Right rear of hous. Left gh side f ho' e, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State f r_ fd Zip Code ;
`-.i C llC
f 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 ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: �"®' `
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle Uoense Number
Bateson Enterprises Ina
Company
7. Lo-catioffWPere contents-were disposed:
G L S' ' Lowell Waste Water
SignAhje Haule Date
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