HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 487 WINTER STREET 8/9/2019 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record AUG o 9 2010
Form 4 ,.
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form,check with your
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/Righf4ront ofy� house.�#I Right rear^of house, Left/right side of house, Left
Right side of building, Left/Right ront of building, Left/Right rear of building, Under deck
Address
Citylrown �— State Zip Code
2. System Owner.
, O
Name
Address(if different from location)
Citynown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2.Quantity Pumped: Gallons 1 O C
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes C5�No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �I
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationwhere contents were disposed:
G L S. Lowell Waste Water
_b-A
Signitule 9f Haul Date
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