HomeMy WebLinkAboutSeptic Pumping Slip - 217 GRAY STREET 3/22/2016 Commonwealth f Massachusetts RECEIVED
_ it" ®run of
YS
DEP has provided this form for us&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. S stem Locatio�- ,,Cg efr � r ht ront o ha
Right side of bri Left/Ri ht -
y g use,"aLeft/Right rear of pause, Left/right side of pause, Left/
g g front of'6-uildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: �d
Name'
Address(if different from location)
City/Town States� � z` Cade ;
.,, O
Telephone Number
r
i
.-.
B. Pumping Rpcord }.
1. Date of Pumping 2. Quantity Pumped: —
Date .. Gallons
3. Type of system: E] Cesspool(s) ltkc Tank ❑ Tight Tank
❑ Other(describe): ...
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? No,
5, Condition of System: Iry
6: System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Ehterprises Inc'
Company
7. Locatapgta, w ere contents were disposed:
C L S AHaule Lowell Waste Water
. .. �
9
Sign a Date
tfiforrM.doc•06/03 System Pumping Record•Page 1 of 1