HomeMy WebLinkAboutSeptic Pumping Slip - 42 VEST WAY 8/5/2016 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping.Record 201
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Farm 4 IMN OF NORu M'00VUR,
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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. System Location: Left h front of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rrg ran of building, Left/Right rear of building, Under dock
Address
L(I �_ *V0_(A-
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State-
Telephone Number
r
i
.B. Pgmp►tng.Record
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type-of system; ❑ Cesspool(s) 018 pti c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo n wtyere contents-were disposed:
G L S: Lowell Waste Water
Sign a Houle Date
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