HomeMy WebLinkAboutSeptic Pumping Slip - 145 BRADFORD STREET 11/18/2008 CotTimonwealth Of Massachusetts
City/Town of R E ...
System um in g Record N 0 V
mY Form
'VO V"4� i r��c� la i H i'41)OtrER
DEP has provided this form for use by local Boards of Health. Othe fo[ ,may° ease
e �, t t,e
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
Important:
When filling out 1. System Location:Left frpni left rear, left sit h use tight front, right rear, right side of house.
forms on the
computer, use
only the tab key Address },
to move your L. `•e..r ? ..G(>
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
�dv7 Address(if different from location)
City/Town State/'�� (� --� Zig Code
Telephone Number
B. Pumping ecor
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Q eptic Tank ❑ Tight Tank
Other(describe): --
4. Effluent Tee Filter present? Yes F
3No If yes, was it cleaned? [J Yes [ No
5. Condition of System:
,�NC
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
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