HomeMy WebLinkAboutSeptic Pumping Slip - 426 SUMMER STREET 7/18/2016 Commonwealth of Massachusetts
City/Town of . ,
S YS
t Pumping. rd
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 fora they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. In ®r ti®n
1. S y s•tem Location: Left/Right fro nt of house Lef 'w. ar ofµh.. ,.,
Vie, Left/right side of house, Left/
Right side of building, Left/Riga front of building, Left/Right rear of building, Under deck
Address
city/rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
1'ilfy/TOwn e ...
Telephone Number
r
13. P'urrlrping Record f �
1. Date of Pumping Date ��epfic uanti Pumped: Lallans
3. Type of system: ® Cesspool(s) Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ® Yes ® No,
5, Condition of stem:
4 � _f
6; System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationere contents were disposed:
S. Lowell Waste Water
Sign a I Houle a Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1