HomeMy WebLinkAboutSeptic Pumping Slip - 40 DUNCAN DRIVE 3/10/2017Commonwealth of Massachusetts
City/Tow
yste p g ec rd
,
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 Informatior
1. System Location: Left / Right front of house, Left / fht rear of liOiiii?Left / right side of house, Left /
Right side of building, Left / Right front of building, Leff7Riat rear of building, Under deck
•
Address
City/Town
2. System Owner:
Name'
Address (if different from location)
City/Town
P
1. Date of Pumping
ec d
. Type of system':
Other (describe):
4. Effluent Tee Filter present? E] Yes j-
5.
Condition of System:
Nos -
Date
Cesspool(s)
State
Zip Code
Telephone Number
2. Quantity Pumped: Gallons
00, ee"
eptic Tank 0 Tight Tank
r
If yes, was it cleaned? D Yes Ej No.
6: System Pumped By:
Neit Bates -on
Name
Bateson Enterprises Inc.
Company
7. Location WI- c ntents were disposed:
GLSJ Lowell Waste Water
F5821
Vehicle License Number
Signtufe qt Haul Date
rr•
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