HomeMy WebLinkAbout- Septic Pumping Slip - 46 WINTERGREEN DRIVE 1/8/2019 Commonwealth of Massachusetts
J
City/Town of %
System Pumpling Record
Form 4
DEP has provided this form for use-by local Boards of-Health. Other forms maybe but the
information,must be substantially the tame as that provided here. Before using.this form,check with your
ioca*i 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 authority.
A. Facility InforMation
1. System Location: Left/Right front of hous 'RIght1?e_aEqjhous)Left./right side of house, Left
I
p
Right side of building, Left Right front of bU216g., I-eft I Right rear of building, Under deck
Address
1--t ,
State
City/Townstate Zip UO'de
2. System Owner. LC
mama'
Address(if different from location)
cityrrown Stater
Telephone Number
.13. Pumping Kocord
I Date of Pumping Date 2.
'u' City Pumped: Gallons
3. Type-of system: El cesspool(s) Septic Tank E] Tight Tank
C) Other(describe):
4. Effluent Tee Filter present? El Yes M40 If yes, was it cleaned? Ej Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell,Batesbri F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-wher-e contents-were disposed:
Lowell Waste Water
sign V0b_f_ —HbulmU Dai;_
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