HomeMy WebLinkAboutSeptic Pumping Slip - 547 WINTER STREET 5/23/2016 : 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 Location4�Aight t of hoouss Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
City/Town (�J�J State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown 1 de ;
Telephone Number '
.B. Pumping Record v C
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 9-5e--p—tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye-s No 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. Loq%ion where contents-were disposed:
., G L Lowell Waste Water
SignAWe I Haul Date
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