HomeMy WebLinkAboutSeptic Pumping Slip - 222 BRIDGES LANE 11/4/2016 Commonwealth of Massachusetts RECEIVED
�. CitWTown of
NOV °G
System Pumping-Record
F+YS 4 TOT OF i�gC'�l�'x'"k1 A�� OV
14 ALTH DEPARTP1L�0'T
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 ont of housed Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ront o building, Left/Right rear of building, Under deck
Address f
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town ' State Zip Code
Telephone Number
r
i
.B. Pumping Record
1. Date of Pumping Date �l r uan#ity Pumped: 5C
Gallons T
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Local ors
wh
re contents-were disposed:
G�.5: Lowell Waste Water
Sign t e Haule Date `
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
P