HomeMy WebLinkAboutSeptic Pumping Slip - 145 OLD CART WAY 5/24/2016 Commonwealth u ( rvnex ,
= r City/Town of
S ' tem Pumping, Record
YS
ry
a
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the
information must be substantially the tame 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. System Locatio�ef� igl ont of hou Left/Right rear of house, Left/right side of house, Left/
Right side of bul ing, Left Righili6ffa buildinig, Left/Right rear of building, Under deck
Address
Citylrown State ..-3 Zip Code
2. System Owner:
Name'
Address(if different from location)
City/'rown State Zip Code
Telephone Number '
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ®'`tJo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: .
c ', x ►
CF
6: System Pumped By:
Neil.Batesian F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo
cation , here contents-were disposed:
C L S. f Lowell Waste Water
E)� l
Sign a Houle Date
t5form4.doo•06/03 System Pumping Record•Page 1 of 1