HomeMy WebLinkAboutSeptic Pumping Slip - 85 WINDKIST FARM ROAD 6/13/2016 Commonwealth of Massachusetts R
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System Pumping Record ""U �10
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DEP has provided this form for use=by local Boards of Health. Other forms m,ay 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. Infr tip►
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
. .�
Citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityll"own Sta ;"w �,. Zip Cade
Telephone Number
B. Pumping Record — �..
1, Date of Pumping Date 2. Quantity Pumped: Gauons r
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes 240 .. .,., If yes,was it cleaned? ® Yes ❑ No,
5. Condition of stem: ` o; c, � W � w
. f.. . - . c
6: System Pumped By:
Neil.Bateson F5621
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
o G LAS. Lowell Waste Water
(�tigne Haule Date
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