HomeMy WebLinkAboutSeptic Pumping Slip - 742 WINTER STREET 10/11/2016 RECEIVED
Commonwealth of Massachusetts
s 616
City/Town of .
system Pumping.Record
Farm 4
DEP has provided this farm far use-by local Boards of Health. Other forms maybe`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 Ight front of house;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
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ' State ? ► Zip Code ;
Telephone Number ,
i
B. Pumping Record
1. Date of Pumping Date 2. Quin tity Pumped: Gallons -"
3. Type-of system: ❑ Cesspool(s) eptie Tank n Tight Tank
r .
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ff No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: >
7
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatiprl-m(hre re contents were disposed:
^L S. Lowell Waste Water
Sign a 9t HbuieV Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1