HomeMy WebLinkAboutSeptic Pumping Slip - 56 WINDKIST FARM ROAD 10/17/2016 : Commonwealth of Massachusetts
City/Town of '
Sy' t+em Pumping.Record
.. Form 4
y
DEP has provided this form`for useaby local Boards of Health. Other forms may be'used but the
informatlon'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
1. System Location: Left/Right front of house, Left!Right rear of house, Left g_ht side of h�r� Left/
Right side of building, Left/Righ t front of building, Left/Right rear of building, Under deck
Address
,
City/Town State .Zip Code
2. System Owner.
C&
Name'
Address(if different from location)
City/Town ' State
,feu(, ,.� Zip Code
F Telephone Number +"
.B. Pumping Itacord
1. Date of Pumping date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatio a contents-were disposed:
LS Lowell Waste Water
Sign a I HaulerU Date
t5farm4.dac•06/03 System Pumping Record•Page 1 of 1
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