HomeMy WebLinkAboutSeptic Pumping Slip - 220 BOXFORD STREET 12/28/2016 Commonwealth of Massachusetts
City/Town of .
System Pumping.Record "
�.. Farm 4 , .
• I l�
DEP has provided this form for use-by local Boards of Health. Other rrft,
AMPY b� 'used, but the
Y P i6eck with our
information must be substantially the same as that provided here. Befo 'ptasipg:f y
local Board of Health to determine the form they use.The System Pumping Record be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I. System Location: Left I Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right€rant of building, Left I Right rear of building, Under deck
Address��p \}
Cityfrown State Zip Cade
2. System Owneer.
4 ;N'»_r
Name'z
Address(if different from location)
City/Town ' State Zip Code
Telephone Number
.B. Pumping kecord
1. Date of Pumping p �-�---- 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:
6.• System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
b
L S: Lowell Waste Water
Sign a Houle pate
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