HomeMy WebLinkAboutSeptic Pumping Slip - 59 NORTH CROSS ROAD 5/16/2016 Commonwealth Of Massachusetts
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City/Town of RE
S item Pumping-
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DEP has provided this form for use=by local Boards of Health. Oth&ib"st inay 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 Location: Left/Right front of house, Left/I�lglit rear_ Vof�hc�use; Left/right side of house, Left/
Right side of building, Left/Right front of building, 'Left/Right rear of building, Under deck
Address t �- C \ (
1
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citynown State ? Zi Code
Telephone Number
B. P p in - record
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-1110 If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: Q µ _
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc,
Company
7. La do v_ ere contents were disposed:
G L S. Lowell Waste Water
Sign a cf Haule Date
t5form4.doo•06/03 system Pumping Record•Page 1 of 1