HomeMy WebLinkAboutSeptic Pumping Slip - 427 WINTER STREET 5/16/2013 Commonwealth of Massachusetts
City/Town of
System Pumping Record
r 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/45i t ear of hou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner: l
� Y-)o v
Name'
Address(if different from location)
Cityfrown State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-9-0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
S• Lowell Waste Water
f(c�r t 3
SZte Haul e Date
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