HomeMy WebLinkAboutSeptic Pumping Slip - 440 WINTER STREET 5/1/2017 itsMassachusettsRECEIVED
City/Town of
S tem ffi '
YS
Form
b @
DFP has provided this for. for use-by local Boards of Health. Other forms may be'used, 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 form they use.The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Facility, Information
1. System Location: Left/Fight front of Hous , 6 ight r bf hou , Left/right side of house, Left/
Dight side of building, Left/Right fr6nt of building, Left/Right rear of building, Under deck
Address
,— c
citylrown State Zip Code
2. System Owner
Name`
Address(if different from location)
City Town tat e,. Zap
1
Telephone Number _ �w
Ptlimping kecord
1. Cate of Pumping Date 2. Quantity Pumped:
iGallons
. Type-of system: Cesspool(s) eptic Tank D Tight Tank
[� Other(describe):
4. Effluent Tee Filter present? D Yep o If yes, was it cleaned? D Yes El No,
. Condition of System:
6: System Pumped By:
Nelf Bat on F5821
Name Vehicle License Plumber
Bateson Fr�es Inc
Company
7.jSigne
here contents rnrere disposed:
Lowell Waste`Water
I�aui -date
-
_L
06/03 system Pumping Record Page f of 1