HomeMy WebLinkAboutSeptic Pumping Slip - 781 WINTER STREET 12/9/2017 _ Commonwealth of Massachusetts
y C!tV/Town of .
System Pumping.Record
Form 4
DEP hasprovidedthis form for use-by local Boards of Health. Other forms maybe used, but the
information•must be substantially the same as that provided Dere. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted teo
the local Board of Health or other approving authority.
A. Facility Inforiri�a#ion-
1. System Location: Left Rightht front of Hous weft!Right rear of house, Left/right side of house, Left 1
Right side of building, Left 1 Right front o building, Left 1 Right rear df building, Under deck
Address
Citynown state Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown ' State" Zip Code ;
Telephone Number `p
.B. Pumping Record �
1. Date of Pumping °t l - Quantify Pumped:
Date Gallons
3. Type-of system: ® Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
' S. Condition of System:
6; System Pumped By:
Neil.Bateson F6821
Name Vehicle License Number
Bateson Este rises Ina
Company
?. LocaVo re contents were disposed:
GLS: Lowell Waste Water
• q
F B
Sign a cf Haule Date
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