HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 WINDKIST FARM ROAD 11/27/2019 Commonwealth of Massachusetts
y City/Town of RECEIVED
System Pumping Record
Form 4 NOV 2 7 201 a
DEP has provided this form for use=by local Boards of Healthrfused, but the
information must be substantially the same as that provided he Reis 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/Right front of house, Left/Right rear of house, Left/r side of house, ft 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 1
City/Town State Zip Code
2. System Owner.
Name V�-
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping record _
1. Date of Pumping Date 2. Qua ty Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ; epficTa"nk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LJ 'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location a content were disposed:
_L -P Lowell Waste Water
Signitute 4#Haul Date
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