HomeMy WebLinkAboutSeptic Pumping Slip - 15 NORTH CROSS ROAD 6/13/2016 Commonwealth of Massachusetts RECCEIVED
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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 forrh 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/Right rear of hour. Left,. righ ide 8f house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck"
Address z .w. m.� "
Citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town States ,, L �ip Code
Telephone Number
Pumping Record _ ..,
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type•of system. ❑ Cesspool(s) ❑ eptic .w,..
Tank [I Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ,-No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Locatio here contents-were disposed:
GCS. Lowell Waste Water
Sign WHa Date
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