HomeMy WebLinkAboutSeptic Pumping Slip - 46 WINTERGREEN DRIVE 12/4/2017 Commonwealth of Massachusetts
w City/Town of . ECEIVED
Oterin Pumping.Record
Form 4
TOW 01'"NOW[I M11)OVER
DEP has provided this form for use-by local Boards offlealth. Other forms 1 I e
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. Inform' ation
1, System Location: Left/Right front of douseRig rear o e, Left/right side of house, Left
Right side of building, Left/Right front of bulleLeft/Right rear of building, Under deck
Address " �� %`a°" . -..
Cityrrown State Zip Code 1
2. System Owner:
"( \I\-,e-
Name'
Address(if different from location)
Citylrown State Zi Code
&� '
Telephone Number
_ . Pumping JRecord .
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. T e•of s
Type-of y.stern:
® Cesspool(s) ' Q.- p�"tia Tank [I Tight Tank
® Other(describe):
4. Effluent Tee Filter present? El Yes a If yes, was it cleaned? ❑ Yes ® No,
' 5. Condition of System:
6. System Pumped By:
1
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. LocatiArvv�i, contents-were disposed:
' f
_L S: Lowell Waste Water
E) 7
4SignAWe qf Haul Date
t5forrn4.dor,-06/03 System Pumping Record Page 9 of 1