HomeMy WebLinkAboutSeptic Pumping Slip - 32 EQUESTRIAN DRIVE 5/17/2016 Comm
On wealth of Massachusetts
_ i • wn O .
YS
item Pumping.Record
Form
DEP has provided this form far 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
I. System e Right h l.,a r.mm of hou
s ' Left right side of house, Left
Right side of building, Left Right front of building, Left jhroar bRbilding,
Under deck
Address °° a E
City/Town V State Zip Coale
2. System Owner:
Name
Address(if different from location)
CityfTown ' C ;
. State Zi f ��,„ � de p-
F.
Telephone Number
B. Pumping Record
1, Date of Pumping 2. !Quantity Pumped:
Date Gallons
3. Type-of system: ❑ Cess ool saSeptic Tank ❑ Tight Tank
❑ Other(describe):
p ❑ Yes ❑,+ro
4. Effluent Tee Filter resent? If yes, was it cleaned? El Yes ❑ Na,
5. Condition of System:�'
6; System Pumped By:
Neil.Batescm F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G S. Lowell Waste Water
SignAtu Fe qf Haule Date
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