HomeMy WebLinkAboutSeptic Pumping Slip - 88 PHEASANT BROOK ROAD 10/3/2016 :-C-\ Commonwealth of Massachusetts
.. City/Town of
System Pumping.Record
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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 farm 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/Right franc of house, Left/ fight rear of pause)Left/right side of pause, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address G<l
_115 c
City/Town state Zip Code
2. System Owner.
Name*
Address(if different from location)
City/town State Zip Code
Telephone Number
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Y
B. Pumping.Rmcord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Nell.Bates-on F5821
Name Vehicle License Number
_Bateson Enterprises Ina
Company _
7. Location„ There contents-were disposed:
C S.
Lowell Waste Water
Sign a I Ftaule Date
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