HomeMy WebLinkAboutSeptic Pumping Slip - 90 WINDSOR LANE 11/28/2017 Commonwealth of Massachuseffs
City/Town of
• � system Pumping.Iger
Form 4
DEP has provided this form'for use=by local Boards ofiHealth. Other forms maybe•used, but the
informafion•must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forlin they use,The System Pumping Record must be submitted tc j
the local Board of Health or other approving authority.
A. Facility. Information
I. System Location: Left/Right front of house, Left/Right rear of house, Left I tide of se
of
Right side of building, Left I Right front of building, Left l Right rear of building,�Wrac• c
�.w
• ,address
Cityffown State - Zip Code
2, System Owner: 1
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number
® Pumping Rpco °d j �
C(— (1� ✓!c 04
1. Gate of Pumping pate 2. Quantity Pumped: Gallons ��`
3. Type-of system: El Cesspool(s) ' ept c Tank ® Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes N`o ___ If yes, was it cleaned? ❑ Yes F1 No,
a. Condition of System-
�''`S G Yv11
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company t
7. Locatjon here contents were disposed:
OSQLowell Waste WaterSigne —date
Mbrm4.doc•08/03 System Pumping Record.Page 9 of 1
