HomeMy WebLinkAbout- Septic Pumping Slip - 56 WINDKIST FARM ROAD 10/31/2018 Commonwealth of Massachusetts FtECEIVED
City/Town of
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Systm Pumpling RGcord -R
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Form 4 T��IDEPAR'TME�4T
DEP has provided this form for use-by local Boards of Health. Other forms maybeused,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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving suthorlly,
cirity InforMation
1. System Location: Left/Right front of house, Left/Right rear of house, Left. of—h—ouo—s Left I
n s ,
Right side of building, Left Right 66nt of building, Left/Right rear of building, Uiid OR
Address kC1
city/Town "State Zip Code
2. System Owner
Name'
Address(if different frosty 10[Caftn)
CilyfTown Stater Z' Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Qu6nfity Pumped: Gallons
3. Type-of system: E] Cesspool(s) S--§eptic Tank El Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? El Yes 0 If yes, was it cleaned? ED Yes El No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F6821
Name Vehicle Ulcense Number
Bateson Enterprises Ina
Company
7. Lor_atiioniA�r contents were disposed:
G-L S. Lowell Waste Water
Sign e Hbul Date
t5fbrm4.doo-08/03 System Pumping Record®Page 1 of 1