HomeMy WebLinkAboutSeptic Pumping Slip - 80 WINDKIST FARM ROAD 1/17/2017 jCs\ Commonwealth of Massachusetts
City/Town of
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DEP has Provided this forrni for use-by local Boards of Health. Other forms maybe bled, 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 forth they use.The System Pumping Record must be submitted fic)
the local Board of Health or other approving authority.
A. Facility, Information �
I. System Location igh CrontcifMous , Left/Hightrear of house, Left/right side of house, Left/
Right side of buil in , Left!Pton of buildirig, Left/Right rear of building, Under deck
Address 1
City/rown State Zip Coda
2. System Owner:
- 0 k .LL
Kama'
Address(if different from location)
City/Town ' Stater Zip Cods
t Telephone Number
i
® Pum
ping .
1. Cate of PumpingDate 2. Quantity Pumped
Gallons
. Type-of system: Cesspool(s) ptic Tann: Tight Tanis
El Other(describe):
4. Effluent Tee Filter present? [j Y"e o if yes, was it cleaned? Yes No,
. Condition of System
6: System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson �hterprises Inc
Company
7.4ftne,
re contents-were disposed:
Lowell Waste Water
l mate f
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