HomeMy WebLinkAboutSeptic Pumping Slip - 46 WINTERGREEN DRIVE 12/13/2016 Commonwealth of Massachusetts
City/Town of . w I '
a
System Pumping-Record
Form k a.�,.e �.� Y 101
���:►1 �i�'th�R
� rP by local s� eOther
fomation must be substantially the tame as that provided he. Before e
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!Right front of hou , L`eft/Ftig rear of hpus , Left/right side of house, Left
Right side of building, Left/Right front of bu g, Left/Rig_hT rear of building, Under deck
Address
CIWTown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown ` state
Telephone Number +`
.B. Pumping Record
1. Date of Pumping date 2. Quanti --Pumped: Gallons 4--'——.
3. Type-of system': ❑ Cesspool(s) a1eptIcTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
v ,
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc`
Company
7. Lo tia when' contents-were disposed:
G L Lowell Waste Water
cJA Ba
si-04146 qf Hbule Date
t5form4.doc 06103 System Pumping Record•Page 1 of 1