HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WINTERGREEN DRIVE 6/24/2021 :Yq\.- Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record ��� 2 ,6 NZ,
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe used,but the
information,must be substantially the two 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 a lgh front of hou , Left/Right rear of house, Left/right side of house, Left 1
Right side of buit mg, Left/Right froff_dT building, Left/Right rear of building, Under deck
Address
Citylrown state Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State ��� � • Zip Code,'
Telephone Number (��+
6. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L 9O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location wh contents-were disposed:
S Lowell Waste Water
LlraA. Pna�'
signwefHaulev Date
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