HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 55 WINTERGREEN DRIVE 10/1/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for um-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 forrim they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authoft
A. Facility Information
1. System Locatio a Righ nt'of�houseft/Right rear of house, Left/right side of house, LeftRight side of bu g, Left/Rig roig, Left/Right rear of building, Under deck
Address _/ , ^ -,
Gb/n'own State Zip Code
2. System Owner r
CC
Name"
Address(if different from location)
Cilylrown Code
z 9? c-�z
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9-90 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 4�-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo re contents-were disposed:
G_ S Lowell Waste Water
Sign a Haul Dabs
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