HomeMy WebLinkAboutSeptic Pumping Slip - 499 WINTER STREET 10/16/2017CO
1. Date of Pumping
Cornmonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
Or
1 6 Z011
T DEP has provided this form. for use by local Boards of Health. Other fo(WN r)e
viriF6N97:16ORTH A.46aNDO\,1yrbEuRt the
informationmust be substantially the same as that provided here. Before using this form, check with your
lope! 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 house, Left / Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Right frOnt of buildirig, Left / Right rear Of building, Under deck
City/Town
2. System Owner:
PeAt(--
State Zip Code
Name.
Address (if different from location)
City/Town '
Telephone Number
B. Pumping Record
Date
3. Typecf system'. EI esspool(s) eptic T nk 0 Tight Tank
irk
azicer (describe):
4. Effluent Tee Filter present? 0 Yes
' 5. Conditionpsystem:
(7
2. Quantity Pumped:
Gallons
If yes, was it cleaned? 0 Yes E1 No,
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Lo wherecontents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Sign e Hauler( Date
5f 06/03 System Pumping Record • Page 1 of 1