HomeMy WebLinkAboutSeptic Pumping Slip - 46 WINTERGREEN DRIVE 9/15/2015 : Commonwealth of Massachusetts
CRWTown 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 Location: Left/Right front of tious ,�L�e /Rig �ofho e, Left/righ t side of house, Left Right side of building, Left/Right front of bui ding, Left/Rf building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name-
Address(if different from location)
3
Citylrown State Zi de ;
4-1 L - Y3
Telephone Number
B. Pumping JRacord �.
1. Date of Pumping Date 2. Quantity 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 System: `-
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
LS, Lowell Waste Water
f
SignAtufe I HaulerU Date
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