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HomeMy WebLinkAboutSeptic Pumping Slip - 90 WINTERGREEN DRIVE 10/4/2016 Commonwealth of Massachusetts City/Town of System Pumping.Record Form 4 DEP has provided this form for use-by focal Boards of Health. Other forms may be used, but the information,must be substantially the tame 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. Right of building, Left/Right front of buildin e I ht r 1, System Location; Left/Right front of house, Le f# Fri�ht rear of house;Left/right side of house, Left/ g g, g g, g ear of building, Under deck Address q0 j CIWTown State Zip Cone 2. System Owner. Name. Address(if different from location) Cityfrown ` State Zip Code Telephone Number .B. Pumping Record 1. Date of Pumping Dahl -- 2. uantity Pumped. Gallons 3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe); 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes © No. 5. Condition of System: . 6. System Pik i ed B C p Y Nell.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Location where contents-were disposed: c s: Lowell Waste Water . ............. Sign a I Houle Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 j