HomeMy WebLinkAboutSeptic Pumping Slip - 42 BANNAN DRIVE 12/28/2016 ECEIV ED
Commonwealth of Massachusetts
i a� ..0 H 01 �
p g • 4dvpp dWG$EPI, M )H,, m d ()V
E,4
DEP has provided this for m for use=by local Boards 6f Health. Other formt may be'used, 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;3ystern Pumping Record must be submitted t
the local Board of Health or other approving authority.
A. Facility, Information
1. System Location 06 ` Rig front�f hour, Left/Right rear of house, Left/right side of house, Left t
Right side of buil n Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state dip Code
2. System Owner:
Name*
Address(if different from location)
City/Town ' state Code
n Telephone Number
1
Pumping iif6 r
1. Date of Pumping rate 2. Quntity Pumped: Gallons
. Typ&of systern. Cesspool(s) eptic Tank Ej Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yep Plc If yes, was it cleaned? Yes Igo,
' 6. condition of.System* .� �i 'k
6: System Pumped By:
Jell.Batesbn F5821
Name Vehicle License Dumber
ateson Enterprises Inc"
Company
7. LocaVon. ,re contents-were disposed:
G� S'. Lowell Waste Water
F
Sign a Houle Date
Morrn4.doc-06/03 System Pumping Record gage 1 of 1
"