HomeMy WebLinkAboutSeptic Pumping Slip - 11 BRIDGES LANE 12/13/2016 w Commonwealth of Massachusetts
Cjt�/Town of RECEIVED
SY.4tem Pumping.Record
�1 fl�I or N01�:�51 i At4lw"�r�VE
® P has provided this form'for use-by local Boards of Health. Other forth° i e ;but the
Information-must be substantially the tame 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 tc)
the local Board of Health or other approving authority.
A. Factlity, Infor t6®n
1. System Location; Left/Right front of douse, Left ig rear of h so;Left/right side of house, Left
Right side of building, Left/Right front of building, eft/Right rear of building, Under deck
Address .. .._.,
.
cityfrown Mate Zip cotle
2. System Owner: ,
Name'
Address(if different from location)
cityfrown Stater
AC c?
F
y
Telephone Number ` 4
i
® r
1. Cate of Pumping pate 2. Quantity Pumped- Gallons
3. Type-of systerrt, Cesspools) eptic Tank Tight Tank
El Other(describe):
4. Effluent"fee Filter present.? [ED] Yep No If yes, was it cleaned? E Yes EJ Igo,
. Condition of.System:
5: System Pumped By:
Nell.Bat bn ` F5321
Dame Vehicle Llcense Number
Bate on Enterprises Ina
Company
7. Location r-here contents-were disposed.
S. Lowell Waste Water
w f
Sign a Whule pate
l5forrm.doo®06/03 System Pumping Record Page 1 of 1