HomeMy WebLinkAbout- Septic Pumping Slip - 502 WINTER STREET 10/2/2018 p s
t�/Town of
SYMem Pumpang,Record
Form 4 �,,-'U, H `),_r� ' i n•f!�
DEP has provided this formi for use=by local Boards of Health. Other forms maybe used,but the
information,must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forth they use.'The;Systern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Fad4ty, InforMation
i
1. System Locatio , L Rig of hour Left/Right near of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear(if building, Under deck
Address t- rE-,,-, q iC�r � AA�,grTL5zc
City/rown 4r•' `State- f�,f Zip Code
2. System Owner:
Address(if different from location)
City/Town ' Stet ! ip Code
Telephone Number "`r
i
Pumpling
yy . r
- �Pe)
1. bate of Pumping Date 2. Quantity Pumped: Gallons `
3. Type-of system', El besspool(s) eptic Tank 0 Tight Tank
® Other(describe):
i
4. Effluent Tee Filter present.? El Yet o if yes, was it cleaned? ® Yes No,
` 5. Condition of system: �,.�Z1'�.J'���✓L �,�..�../ \I'w� ��C� �t �-� ....-(, �
Vim.` •
6; System Pumped By:
Neil.�ateson F6621
Name Vehicle License Number
Sateson Enterprises Inc-
Company
7. Lora'7,/wentents•were disposed:
G Lowell Waste Water
Sign Clete
t5forrn4.docb 06/03 ,System Pumping Record*Page R of 1