HomeMy WebLinkAboutSeptic Pumping Slip - 1538 TURNPIKE STREET 6/30/2016 Commonwealth of Massachusetts
Cjt�/Town of RECEIVED
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item Pumpin§.
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DEP has provided this fora 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 Ahis 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 ai n
I. System Location: Left/Fight front of housed/Right rear of house, Left/right side of house, Left/
Right side of building " /- ig tali of buildin �Left/Right rear of building, Under deck
Address —°- y
City/Town State - Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State r
Zip Code
. C.wJ ���,. -5
,).,_ l e
Telephone Number `4>
Pumping.Record _ �
1. Gate of Pumping Date ' 2. Quantity Pumped: Gallons Y
3. T e•of s stem:
Type-of y ❑ Cesspool(s) eptic Tank El 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 Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
G LJS. ,. Lowell Waste Water
.,
Sign a PaulerU Date
t5form4.doo•06/03 System Pumping Record•Page 1 of 1