HomeMy WebLinkAboutSeptic Pumping Slip - 538 WINTER STREET 11/17/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of . w ' �Q,01
System Pumping-Record rowN OF N Mr)OVER
r Form 4 HEALTH OEPARTMENT
DEP has provided this form for use„by local 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
1. System LocatioL� Rig t ��of e, Left/Right rear of house, Left/right side of house, Left/
Right side of bul ding, left/RiACT
rant of building, Left/Right rear of building, Under deck
. Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ' State ) ip
Telephone Number
.B. Pumping lRecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ spool(s) ptic Tank ❑ Tight Tank
ther(describe): 1,
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No,
' S. Condition of System: `
. 1 r
6: System Pumped By:
Nell,Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
be_�
Company
7. Lo orl contents were disposed:
G S a Lowell Waste Water 3
f
Sign a Heule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1