HomeMy WebLinkAboutSeptic Pumping Slip - 162 ABBOTT STREET 3/10/2017Commonwealth of Massachusefts
City/Town of
ystem Pu ecord
Fo 4
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 forrn, check with your
Iocal Board of Health to determine the form they use. The System Pumping Record must be submitted to
the Iocal Board of Health or other approving authority.
• *FIFEC„: El • E D
'TOWN OF NORM ANDO \TER
NEALTH DEPART NIETO"
• A. Facility Informatiop
1. System Location: Left / Right front of house4efQRght ar or hoiik Left / right side of house, Left /
Right side of building, Left / Right front of bullbuflcflig, Left / Rig reaFrbuiIding, Under deck
Address
City/Town
2. System Owner
Name*
Address (if different from location)
itvrrown
State
Zip Code
Telephone Number
1
cod
1. Date of Pumping
Date
3. Type of system 0 Cesspool(s) la -Septic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? E] Yes
Condition of System:
6: System PumP'
NeiI Batesbn -
Name
Bateson Enterprises Inc
2. Quantity Pumped:
Gallons
Company
7. Location where contents were disposed:
aL S. Lowell WasteWater
Sign e. Hauls
If yes, was it cleaned? LJ Yes No,
6) A
F5821
Vehicle License Number
Date
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