HomeMy WebLinkAboutSeptic Pumping Slip - 439 WINTER STREET 12/13/2016 -C-\ Commonwealth of Massachusetts
RECEIVED
❑ City/Town of .
S stem Pumping.Record � �
Form 4
I-EA.
DEP has provided this form far use-by focal 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 Location: Left l Right front of house Rig of Vs Left/right side of house, Left
Right side of building, Left/Right front of itding, Left 'Right le building, Under deck
Address °
Co frown State Zip Code
2. System Owner: t
Name'
Address(if different from location)
Cityfrown ' State' Zip Code
Telephone Number ;
ti f
l
B. Pumping keeord
1. Date of Pumping sate 2. Quantity Pumped:
Gallons Y
3. Type-of system: ❑ Cesspool(s) eptllc Tank ❑ Tight Tank
Sher(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:---7 !
6; System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
?4SIgne cati ri�+ir re contents were disposed:
Lowell Waste Water
qf Haule Date
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