HomeMy WebLinkAboutSeptic Pumping Slip - 52 BANNAN DRIVE 12/13/2016 Commonwealth f Massachusetts
City/Town of
RECEIVED
l Record
m
Form i:. .A k.& U N1 ti
DEP has provided this form for use-by local Boards 6f Health. Other forms 0b hW-
information must be substantially the tame as that provided here. Before usinyah1§461ft,Owwwlth your
local Board of Health to determine the for(n they use. The Oystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1 Right side of building, Left/Right front of building, Left/Right rear of gild!"ti��_.
System Right front of Crouse, Left/Right rear of house a ��ht id`s . fio , Left/
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ng, lJn �f pk...w,..
Address
r
City/ro p Code
2. System Owner:
Name'
Address(if different from location)
City/Town - Mate ..,� 4. �", 'L �� ,
"telephone Number
m PuMping Rpcord
1. Date of Pumping crate 2. Quiontity Pumped: ialtons
. Type-of system: Cesspool(s) eptic Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yep If yes, was it cleaned? E] "yes Ej No;
5 Condition of System:
6: System Pumped By:
Neil Bat on F5821
Name Vehicle License Dumber
Bateson Enterprises Inc'
company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Haul Date
t5form4,doc-06/03 system Pumping Record W Page 1 of 1