HomeMy WebLinkAboutSeptic Pumping Slip - 29 WINTERGREEN DRIVE 8/12/2016 Commonwealth of Massachusetts
RECEIVED
City/Townof .
System Pumping-Records
Farm 4 ��� � Iel;���a � �1 �,�� u
• �IEAC
DEP has provided this farm 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 Right front of douse, Left/Right rear of house, Left -Igo t side of
y• g ho a°'Left/
Right side of building, eft/Right front of bulldiiri , Left/Right rear of building, nder dec u
Address � ] 1 9'� m .m-�._�._.--• �" ?�!77�� ,�'"�1 ��,,'�,,, ��
Cityfrown State - Zip code
2. System Owner.
Name'
Address(if different from location)
CitylTown State Zip Code
t 7
r'4
Telephone Number
t
1
.B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons _ T
3. Type-of system. ❑ Cesspool(s) 131860k,"Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U-NO If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition of?Y stem: -
6. System Pumped By:
Neil Batesg, F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo;atQ a contents-were disposed:
G LS'. Lowell Waste Water
Sign a I HauleV Date S
t5form4.doc•06/03 System Pumping Record•Page 1 of 1