HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 547 WINTER STREET 11/4/2019 : Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 LocatioC. Lneg,
g nt of hou , Left/Right rear of house, Left/right side of house, Left
Right side of bu Left/ of building, Left/Right rear of building, Under deck
Address
Citylrown '-t State Zip code
2 System Owner.
Name"
Address(if different from location)
citylTown State ( apCod
e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ cesspod(s) l.IJlSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�C. q
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a contents-were disposed:
G L S Lowell Waste Water
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