HomeMy WebLinkAboutSeptic Pumping Slip - 158 FOREST STREET 9/28/2015 Commonwealth of Massachusetts
= City/Town of
Stem 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/ i fi fro�hous Left/Right rea r of house, Left/right side of pause, Left Right side of building, Left/Righlding, Left/Right rear of building, Under deck
Address
City/Town Y State Zip Code
2. System owner.
Name'
Address(if different from location)
Cityrrown ' State Zip Code ;
Telephone Number `
i
B. Pumping Record �.
Date of Pumping
Date Qua rttity Pumped: Gallons y—
1. 2.
3. Type-of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: s
z)
6. System Pumped By:
Neil.Batesbn ' F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loca' re contents were disposed:
G L S: Lowell Waste Water
Signitu I Fe Haule Date
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