HomeMy WebLinkAboutSeptic Pumping Slip - 14 PURITAN AVENUE 4/11/2016 Commonwealth f Massachusetts ; C {
City/Town of .
YS t um i rc�
Forth 4 i. O M)0�/E i
i !-JAIL"r!
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
Right side of burl i
I. System Location Ce J Right 9ora ho �, Left/Right rear of house, Left/right side of house, Left/
s
g ng, Left/Right front of uildirig, Left/Right rear of building, Under deck
Address
�.
Cityfrown State--
� ... Zip Cade „
2. System Owner.
Name
Address(if different from location)
Cityrrown '
State ��
t
Telephone Number
B. i
Pumping Record , _ 1
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
YP Sys ❑ cesspool(s) e fic T..,.....
3. T e-af s stem: p ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Igo 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. Locations ere contents were disposed:
G L S. Lowell Waste Water
4 °
Sign a Haule Date F
t5form4.doc•06103 System Pumping Record•Page 1 of 1