HomeMy WebLinkAboutSeptic Pumping Slip - 90 WINDSOR LANE 12/2/2015 . J
:mss Commonwealth Of Massachusetts
City/Town Of .
Y item Pumping-Record
Form 4
DEP has provided this farm 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/Right front of house, Left/Right rear of house, Left/ h_ideaf tyou , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
City/rown State Zip Code
2. System Owner.
Name' /
0 .x
Address(if different from location) +Ir
Cityrrown States_ Zip Code ;
7
Telephone Number
i
B. Pumping Record
- �- '
1. Date of Pumping date 2. Qua ity Pumped:
Gallons ,
3. Type-of system: ❑ Cesspool(s) ` Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6: System Pumped By:
Nell.Bates-on ' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo tiorr-where contents were disposed:
C L S. Lowell Waste Water
AC-0 Y-115 F
Sign a Haule Date
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