HomeMy WebLinkAboutSeptic Pumping Slip - 93 WINTERGREEN DRIVE 10/13/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of
Sy* tee Pumping.Record
Form 4 �40RTH
DEP has provided this form for use-by focal 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
I. System Location: e ig ro 6f -ouse Left/Right rear of house, Left/right side of house, Left I
Right side of building, Left/Rig rant of building, Left/Right rear of building, Under deck
Address
CWrown l— State Zip Code
2. System Owner.
Name'
Address(if different from location)
CIWTown State Zip CeLde
, (
Telephone Number
r
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: `
Gallons
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank r.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
"
S. Condition of System: �., / � � A_
6: System Pumped By:
Neff.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lac itio here contents-were disposed:
G Lowell Waste Water
Sign a ht�ule Date f
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