HomeMy WebLinkAboutSeptic Pumping Slip - 192 STONECLEAVE ROAD 5/1/2017Commonwealth of Massachusetts
City/Town of •
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DEP has provided this form for uselv 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. Information
1. System Location: Left / Right front of house, Left(iiear of hous� Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Rig rear of building, Under deck
2. System Owner:
Name.
Address (if different from local on)
City/Town
Telephone Number
Rec
17
1. Date of Pumping
Date 2. Quantity Pumped:
Gallons
Type.of system': 0 Cesspool(s) E3-1-anic 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes la-t ccir--- If yes, was it cleaned? LJ Yes Ej No,
Condition of System:
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Loca . sere contents were disposed:
Lowell Waste Water
F5821
Vehicle Lionse Number
Sign e. Hauls Date
t5form4.doc. 06/03 System Pumping Record Page 1 of 1