HomeMy WebLinkAboutSeptic Pumping Slip - 186 INGALLS STREET 3/8/2016 Common
wealth of Massachusetts
Cityffown of .
S item Pumping,Record
YS
o e
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 Mgdht front of house;Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right rant of building, Left/Right rear of building, Under deck
Address
City/Town U State Zip Code
2, System Owner:
Name'
Address(if different from location)
City/Town Wee state
Zip Code ;
gym.
Telephone Number
B. Pumping Red :
1. Date of Pumping bate 2. Quanti .Pumped: Gallons
3, Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? No,
" 5. Condition of System:
Q
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-wh re contents were disposed:
Lowell Waste Water
Sign a Haule Date
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