HomeMy WebLinkAboutSeptic Pumping Slip - 55 WINTERGREEN DRIVE 9/7/2016 Commonwealth of Massachusetts C ry
w City/Town of .
0M OF NMTH Mvv[tO"VU
system Pumping.Record
i EA[I'H DEPARTMi jqf,
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe used, but the
informatloa must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
I. System Locatio� C0/Rig wont of h s , Left/Right rear of house, Left/right side of house, Left/
Right side of funding, Left/ ig tVbuildlrig, Left/Right rear of building, Under deck
Address
f ��0A�,
dy/Town state zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrawn ` '. State e
Telephone Number r`
.B. Pumping Kecord ..
1. Date of Pumping Date 2. Quantity tity Pumped: calms
3. Type-of system: El Cesspool(s) ept€c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 340 If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca` where contents were disposed:
,,,�Q-LS.P Lowell Waste Water
Sign a HiauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1