HomeMy WebLinkAboutSeptic Pumping Slip - 70 WINDKIST FARM ROAD 10/26/2015 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 bsed, but the
information must be substantially the same as that provided here. Before using.this form,check with your t
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 house, 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 � 1
�Uy�.c _ _ ..�. , _
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
city/Town ' State ,. Zip Code
Telephone Number
i
t�
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons If f
TOWN N N(x rri,
3. Type-of system: ❑ Cesspool(s) Q S60 is Tank ❑ Tight T6 1
WFiNT
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑,'too If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
RECEIVED
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
7WWP c:
Bateson Enterprises Inc HLI;AL ,„
Company
7. Location where contents were disposed:
L s: '.M Lowell Waste Water
V OA Ba_hm-a
Sign a cfHauleV Date
t5form4.doc•06/03 system Pumping Record•Page 1 of 1