HomeMy WebLinkAboutSeptic Pumping Slip - 114 STONECLEAVE ROAD 10/5/2016 . Commonwealth of Massachusetts
City/Town of . �� ���
4 ,
System Pumping-Record
Farm 4
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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I. System Location: Left I Right front of house, Left 1 t f house~`` eft/right side of house, Left Right side of building, Left/Right front of building, Le g t rear of building, Under deck
Address
Cityrrown State Zip Code
2; System Owner.
Name'
Address(if different from location)
Citylrown ' Stater Afp�Code
t Telephone Number .`
.B. Pumping Record
1. Date of Pumping oats 2. Quanti Pumped: Gallons
3, Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? e-, ® No If yes, was it cleaned? ®mss ❑ No,
' 5. Condition of System:
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location-where contents-were disposed:
eLr_")
Lowell Was te Wafer
aA
Sign Date F
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