HomeMy WebLinkAboutSeptic Pumping Slip - 864 WINTER STREET 9/30/2016 Commonwealth of Massachusetts
r City/Town of .
S stern Pumping-Record
Farm 4 K
DEP has provided this form for use=by local Boards of Health. Other form's 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. f Right �ou `. igh zof house, Left/r ight side of house, Left/
Right side of building, Left/Rigeft/Right rear of building, Under deck
Address
CitylTawn state Zip Code
2. System Owner, / w
Name'
Address(if different from location)
Citylrown ' f State 4 ZI Code 7 x,'
Telephone Number +t.
.B. Pumping Record
1. Date of Pumping ante 2. Quantity Pumped: Gallons —`
3. Type-of system: ❑ Cesspool(s) efts fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition afSystem:�/
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lopation, lc re contents-were disposed:
C 46 �
Lowell Waste Water
u�
Sign oule Date
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