HomeMy WebLinkAboutSeptic Pumping Slip - 675 FOSTER STREET 5/1/2017Commonwealth of Massachusetts
City/Town of
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DaPPSTMENT
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 Infor atio,
1. System Location: Left / Right front of hous
Right side of building, Left / Right frOnt of bui
2. System Owner:
ht rearg tAy:1 e, Left / right side of house, Left /
/ Rig ITr of budding, Under deck
Address (if different from location)
City/To n
Ptir pigi Reco d
1. Date of Pumping
Date
3. Type of system': 0 Cesspool(s)
Ej Other (describe):
4. Effluent Tee Filter present? 0 Yes
" 5. Condition of Sys
6. System Pumped By:
Neil Bates-orl
• Name
Bateson Enterprises Inc
Company
7. Lo tion-wk1ere contents were disposed:
Lowell Waste Water
State
Telephone Number
d
2. Quantity Pumped: Gallons
i Tank 0 Tight Tank
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
Sign Haule Date
t5form4.doc. 0B/03
System Pumping Record Page 1 of 1