HomeMy WebLinkAboutSeptic Pumping Slip - 71 WINTERGREEN DRIVE 8/31/2015 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 Locatio` Righ rout df house,,Left/Right rear of house, Left/right side of house, Left/
Right side of bul Ing, Left/RRI�i tfro of building, Left/Right rear of building, Under deck
Address P
Cityrrown 1 State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State Zip Code
Telephone Number w
B. Pumping Record
1. Date of Pumping Date 2- Quan ity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste r.: ,.-V
!i �/
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-where contents were disposed:
G Lowell Waste Water f
_ F
-919-n a 9t Haule Date
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