HomeMy WebLinkAboutSeptic Pumping Slip - 242 LACY STREET 3/22/2016 4.
Commonwealth of Massachusetts
i City/Town of
RECEI
S item Pump
i .
MPS" . ' �
s.
Forma
CEP has provided this form for use=by local Boards of Health. Other forms may be usdhiivat�th it e r�
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
titan
1. System Location: Left fight front of houses Left I Right rear of house, Left/right side of house, Left/
Right side of building, Le ig t front of building, Left/Right rear of building, Under deck
Address
CRY/Town !� State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code ;
Telephone Number
Pt;m:ping Rpcord
1. Date of Pumping sate / 2. Quantity Pumped:
Gallons
3. Type f e s stem:
Y. ® Gesspool(s) G-Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: j
6: System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo on-vyhere contents-were disposed:
Lowell Waste Water
Sign a Haule Date f
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