HomeMy WebLinkAboutSeptic Pumping Slip - 600 FOSTER STREET 3/8/2016 Comm
on wealth of Massachusetts
City/Town of
S item YS
Pumpling.Record
Form
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. System Location: Left/Right front of house, Left i ear of house Left/right side o,f house, Left/
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address
6,00 -on
City/Town State Zip Code
2. System Owner:
Name'
Address( tion)
f
i
city/Town °���.,p °� s State -Zip Pode ;
i iP,J 'R � i,°°f
Telephone Number
B. Pumping Record �../s
1. Date of Pumping 2. Quantity Pumped: Lallans
Date
mow_ ;
3. Type-of system: ® Cesspool(s) [], ptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? e- ® No If yes, was it cleaned? es ® No,
5. Condition of System:
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
^L S. Lowell Waste Water
Sign a f Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1