HomeMy WebLinkAboutSeptic Pumping Slip - 864 WINTER STREET 9/15/2015 : 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 Locatiol /Rig �ront of house;Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fron of building, Left/Right rear of building, Under deck
Address r �t ,(I ,, / 4 � '
L-� lam,
City/Town State Zip Code
2. System Owner. (1
Name'
Address(if different from location)
City/Town Sty
Telephone Number
B. Pumping Ptecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-4-0 If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of Syste
6: System Pumped By: �J
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-w -eere contents were disposed:
LS. Lowell Waste Water
F
Signi a 9t Haule Date
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