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HomeMy WebLinkAboutSeptic Pumping Slip - 42 JERAD PLACE 12/13/2016 Commonwealth of Massachusetts • R' ' ' D City/Town of S stem Pumping. Record Form 4 TOW,pN�^^�.�e ppMA-(kp�H Aqq^p�pkk���Lb��:�IV��.��� 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 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( eff)Z ig=R' house, eft/Right rear of house, Left/right side of house, Left/ Right side of buildli "" Left/ t5 uildiri Left/Ri ht rear cif buildin Under deck g g, g, g g, Address Cwown State Zip Cone 2. System Owner. Name' < �` Address(if different from location) City/Town State• Zip Code ' v (' _ _ 1 F Telephone Number r B. Pumping ✓Ptecord 1. Date of Pumping date 2. Quantity Pumped: r Gallons r ` 3. Type-of system: © Cesspool(s) Septic Tank ❑ Tight Tank ❑ other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No ' S. Condition of System: 6: System Pumped By: Neil.Bates ri F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location wPh re contents were disposed: .f S Lowell Waste Water Q-PKraSA -(-- 1 Sign a 9t Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1