HomeMy WebLinkAboutSeptic Pumping Slip - 50 JOHNNY CAKE STREET 12/28/2016 Commonwealth of Massachusetts
City/Town of ,
System Pumping.Record
Farm 4
'I"0N U-NOR H AM)OR
HEM_11I D PC,RIIO ifl.
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: Left/Right front of Mouse, Left/Right rear of house, Left/right side of house, Left/
Right side of buildin g, Left Right fro'nj,of building, Left/Right rear of building, Under deck
Address 1, .
Citylrown State Zip Code
2; System Owner.
Name'
Address(if different from location)
cityrrown ' State ��(Zipy Code ;
y �i --7`"1 f
Telephone Number
B. PUmping Record
i1
1. Date of Pumping Date 2• Quantity Pumped: Gallons—
3. Type.of,system: ❑ Cesspool(s) { Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? ] Yes ❑ No,
' 5. Condition of System:
Iv �. .
6 System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7, Location where contents were disposed:
GLLSQ Lowell Waste Water
I 10M Bz6z���
Signitu I fe fHaulev Date
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