HomeMy WebLinkAboutSeptic Pumping Slip - 55 VEST WAY 12/13/2016 Commonwealth of Massachusetts
City/Town o
Sy.4tem Pumpling, r MW
Form
DEP has provided this form far use-by local Boards of Health. Other forms maybe used, but the
information•must be substantially the Larne as that provided here. Sefor rtd rhg thrs fb " b4c with your
local Board of Health to determine the forth they use. The System PurnpI66A �r t submitted t®
the local Board of Health or other approving authority.
A. Facility. Information
1. System Lo Lion: Left I Fight front of arouse, Le rg _rear of hous._;1 Loft/right aids of house, Left f
4 Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
,address
city/rown — state Zip Coate
2. System Owner:
Name'
Address(if different from location)
citylrown tat °., —ZIP c e
F
Telephone number
B. i
-_.
Pumpong Rqcord
1. Date of Pumping I�et 2. Quantity Pumped: Gallons
. Type-of system: El Cesspool(s) eptic Tank E] "fight`tank
El Other(describe):
4. Effluent Tee Filter present? EE] Yep alqo If yes, was it cleaned? 0 Yes El No
" 5. condition ofSysterrt: �sa C� ��
l
6.• System Pumped Sy.
Neil.B a tesbn F5821
Name � Vehicle License Plumber
Sateson Enterprises Inc
Company
7. Location where contents were disposed:
.L Lowell Waste Water
It
Sign a Houle gate
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