HomeMy WebLinkAboutSeptic Pumping Slip - 427 WINTER STREET 12/2/2015 1
Commonwealth ®f Massachusetts
= City/Town of .
y• to 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
I. System Location: Left/Right front of house, Left,�R ah ear of ho su ?Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ,.
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
r:l�b
Cityfrown State -7: ( ", Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua' "ty Pumped:
Gallons y `
3. Type-of system: ❑ Cesspool(s) ® eptic 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.Mason F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatip wh rs contents were disposed:
I-S Lowell Waste Water
LIKOA.
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Sign a Hauie Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1