HomeMy WebLinkAboutSeptic Pumping Slip - 742 WINTER STREET 9/23/2015 Commonwealth of Massachusetts
= City/Town of
System Pumping-Record
Form 4
DEP has provided this form far 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
I. System Location: Left/ 19 ""' ta�f.houuso Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Ai
City/Town State R E `°` d,,
2. System Owner. 2015
1
,
Name � �---T-- E
• uif.hl�lfili � '�", lfwi. di
Address(if different from location)
Cltyfrown ' State ip CqAda
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Telephone hone Number
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.B. Pumping Racord
Date of Pumping
1. p g 2. Quantity Pumped:
Date Gallons
3. Type-of system: El Cesspool(s) Q"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E1,0o 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 where contents were disposed:
L S: Lowell Waste Water
✓ w
Sign a I Haule Date
t5form4.dov 08/03 System Pumping Record•Page 1 of 1
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