HomeMy WebLinkAboutSeptic Pumping Slip - 365 BOSTON STREET 10/12/2016 : Commonwealth of Massachusetts
RECEIVED
City/Town of .
System Pumping.Record
Farm 4 rr�E,�.VEf',w
DEP has provided this farm for use-by local Boards of Health. Other forms may 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/Right front of house, Left/Right rear of house, Left I ht_slde of housed Left I
Right side of building, Left/Right front of buiidirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Cade
f
2. System Owner.
Name'
Address(if different from location)
Citylrown ' state,/-) ('i7
fi Telephone Number ; t
.B.. Pumping Racord
1. Date of Pumping Cake 2. Quantity,Pumped: cations
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank }
❑ Other(describe):
4. Effluent Tee Filter present? �FOIN If yes, was it cleaned? es ❑ No,
5. Condition of Syscterlrt:
t
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Local' he contents were disposed:
C L S Lowell Waste Water
('igIn e Da te
t5farm4.doo*06103 System Pumping Record-Page 1 of 1