HomeMy WebLinkAboutSeptic Pumping Slip - 102 LOST POND LANE 3/22/2016 Commonwealth of Massachusetts RECEIVED
w City/Town of
System in
DEP has provided this form for use by local Boards of Wealth. 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 Wealth or other approving authority.
A. Facility. Information
1. System Location: Left 1 Right front of house, Left/Right rear of hous. ft right _ house' /
Right side of building, Left/Right front of building, Left/Right rear of ul ding, Under deck
Address
�
Citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown ' State Zip de
Telephone Number `—
Pumping Record
1. Date of Pumping 2. Quantity Pumped:
date µ Gallons —`
3. Type-of s stem:
YP Y, ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes � o � If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6.. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
G L S: Lowell Waste Water
—( 6
Sign a Haule Date
06rm4.doc•06/03 System Pumping Record a Page 1 of 1