HomeMy WebLinkAboutSeptic Pumping Slip - 427 WINTER STREET 12/6/2017 : Commonwealth of Massachusetts
_ .C4,/Town of .
System Pumping-Record
Form 4
DEP has provided this forni for use-by local Boards of Health. Other forms maybe bsed, but the
information,must be substantially the same as that provided Dere. Before using.this form,check with your y
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 1 Right front of House, Left1 r ht�rear of hvuse� Left,1 right side of house, Left 1
Right side of building, Left 1 Right front of building, Left 1 Right rear of building, Under deck
Address L t p D`7
CRY/Town state�\J Zip Coale
2. System Owner.
Name'
Address(if different from location)
City/rown ' State, Zt Code
p � 3��cU3
Telephone Number
.B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons T
3. Type-of s stem:
y y. ® Cesspool(s) eptia Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ElYes o If yes, was it cleaned? Yes ❑ Na
5. Condition of System: �
a. System Pumped By:
Nell.Bateson }=5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
p
7. Lo re contents-were disposed:
• p
GLS-Q Lowell Waste Water
Sign HaulMU
Date
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