HomeMy WebLinkAboutSeptic Pumping Slip - 550 WINTER STREET 12/2/2015 • l
Commonwealth of Massachusetts
_ • ity/Town of .
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i to pin rd
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 Right side of buildin
_jk g, Left Right r front of Left/Right rear of house, Left/right side of house, Left/
System
g building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. v ,.
'r
�' ...
Name* ,
. f ,
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping JRpcord
1. Date of Pumping I �✓ ' 2 'Quantity Pumped: Gallons
• Date -�
3. Type s stem:
yp y. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ED Yes M No,
' 5. Condition of System:
4
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca',,n'Wh,ere contents were disposed:
GLS-Q Lowell Waste Water
signAtuTe qf Haule Date(
t5form4.doc•06/03 System Pumping Record•Page 1 of 1