HomeMy WebLinkAboutSeptic Pumping Slip - 80 WINDKIST FARM ROAD 2/8/2016 Common wealth of Massachusetts
City/Town of
Sy* tem 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 Rig hkr r t of housi eft/Right rear of house, Left/right side of house, Left/
Right side of h %trig, Left/Right ron of building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner: `
Name'
Address(if different from location)
City/Town Stat ; err P f (r Code ;
Telephone Number
t
i
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons ,
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sy e
A �LJeA
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
G_ S.Q Lowell Waste Water
(4vr
aA
Signitu a Ha-ule Date
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