HomeMy WebLinkAboutSeptic Pumping Slip - 265 SUMMER STREET 12/28/2016 w Commonwealth of Massachusetts RECEIVED
own of
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DEP has provided this forrni for use-by local Boards 6f Wealth. Other forms may be`used, but the
information-must be substantially the same as that provided here. Before using.this form,check with your
loca,I Board of Wealth to determine the forrh they use.The system Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facilfty, In ®r fun _
1. System Location: Lef 1 ht/u front of house, Left I Right rear of mouse, Left/right side of house, Left I
Right side of building, Left _. lg ron fffiAdBng, Left/Right rear of building, Under deck
Address
CitylTouu+� Mete Zip Code
. System Owner:
r
pay .....5.-,+°"'e✓ YYY Y` .. .
Narrar�`
Address(if different from location)
Cityfrown Mate
P
v Telephone Number
B. t
Pumping
I. Gate of Pumping Efate 2. Quantity Pumped:
Gallons
t
. Type-of system. Cesspool(s) eptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present.? [I Yas o If yes, was it cleaned? El Yes El No
5. Condition of System:
6: System Pumped 6y:
Neil.Sateson F5821
Name Vehicle License Number
lateson Enterprises Inc
Company
7. Location, u re contents-were disposed:
G L 4Haule Lowell WVaste Water
Sign mate
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