HomeMy WebLinkAboutSeptic Pumping Slip - 78 TANGLEWOOD LANE 10/11/2016 Commonwealth of Massachusetts
CKWTown of RECEIVED
S stern Pumping-Record
Farm 4
DEP has provided this farm for use by local Boards of Health. Other forms ff6ay1b6-)6 4d,'bdthe
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/ ig t fret of House, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cttylrown State zip Code
f •
2. System Owner.
Name'
Address(if different from location)
City/Town State `�' �°¢� r ;
Telephone Number :
.B. Pumping R�acord
1. Date of Pumping Date 2. Quantity Pumped: Gallons —
3. Type-of system: ❑ Cesspool(s) eptle Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ` U � L
6; System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
_Bateson Enterprises Inc'
Company
7. Locati n-wh re contents were disposed:
S.P Lowell Waste Water
fi
SjqnX Date
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