HomeMy WebLinkAboutSeptic Pumping Slip - 694 FOREST STREET 11/17/2015 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 Location: Left/Right front of house,LLeft)Righ ear of use % Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
trq d s± AV )yij()yeC'
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
city/Town ' State Zip Code ;
t r"%
Telephone Number
i
• i
B. Pumping fRpcord
( _ 2. Quanti Pumped:
1. Date of Pumping Date ty p Gallons y
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r3
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. Loca"here contents were disposed:
G L . Lowell Waste Water
� . 0 - 1 f
Sign a I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1