HomeMy WebLinkAboutSeptic Pumping Slip - 439 WINTER STREET 11/17/2016 Commonwealth of Massachusetts
4 QWTown of . RECEIVED
System Pumping-Record
Form 4 M
DEP has provided this farm for use by local Boards of Health. Other form ' i the
information must be substantially the same as that provided here. Before lui d. is 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. Informlatlon
I. System Location: Left 1 Right front of hous LeT igh r f how s; Left/right side of house, Left/
Right side of building, Left/Right front of building, Left tR-1jfi rear of building, Under deck
Address
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Tay—frown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' Stated Zip Code ;
Cr
Telephone Number
i
1'
.B. Pumping Kecord
.,
1. Date of Pumping 2. Quantity Pumped: '---,
Date Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System: ❑ UJ Q±—S4
� ,..
6. System Pumped By:
Nell Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lora ' re contentswere disposed:
G-LS.0 Lowell Waste Water
Sign a Houle Date
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