HomeMy WebLinkAboutSeptic Pumping Slip - 781 WINTER STREET 10/28/2016 Commonwealth of Massachusetts RECEIVED
M v . Citj /Town of
NOV
System Pumping-Record
... Farm 4 HEALTH DU,' a�;
DEP has provided this form for usez by local Boards of Health. Other forms may *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 i t front o , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right runt of building, Left/Right rear of building, Under deck
Address d ] t
1
City/rown State Zip Code
2. System Owner, 1
Name
Address(if different from location)
City/Town ' Statp j / Zip Code ;
' f + 1
Telephone Number '4
F
.B. Pumping Record
1. Date of Pumping oat 2. Quantity Pumped:
Gallons k.
3. Type-of system: ❑ Cesspool(s) O Se is Tank ❑ Tight Tank
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio where contents were disposed:
GLS'Q Lowell Waste Wafer
..........
SignAtu a Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1