HomeMy WebLinkAboutSeptic Pumping Slip - 140 COLONIAL AVENUE 11/1/2016 RECEIVED
Commonwealth of Massachusetts
_ City/Town of
System Pumping.Record Il `
Farm 4
DEP has provided this form for use:by local Boards of Health. Other forms maybe 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, RIIgh of house Left/right side of house, Left/
Right side of building, Left!Riglyt front of building, Left I Right rear of building, Under deck
- Address
cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityrrown State Zi Code
Telephone Number G w
i
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6: System Pumped By: .
Nell.Beteson • F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loeati n uv ere�cantents were disposed:
G L S. Lowell Waste Water
- A
PRO
sign a Haule Date F
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