HomeMy WebLinkAboutSeptic Pumping Slip - 118 BROOKVIEW DRIVE 7/21/2016 Commonwealth f ' µ '1
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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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1 Right side of building,ft Left9hRight front of buildini /Left/Right rear of bur d grl Un ededof"h6 us- ;deft/
use
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Address
City/Town State Zip Code
2. System Owner.
Name*
Address(if different from location)
Citylrown ' State/"1, : P def•
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Telephone Number K
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. Pumping ec r �.
1. Date of Pumping Date 2• Quantity Pumped: Gallons i
3. Type-of system. ❑ Cesspool(s) ❑-SepticYTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑""110....., If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition of System: � �.AJ �.•.�� .
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc`
Company
7. Locatiq,rG L S.w hereontents were disposed:
Lowell Waste Water
SignAtu fe I Haule Date
06rrn4.doc•06103 System Pumping Record o Page 1 of 1