HomeMy WebLinkAboutSeptic Pumping Slip - 165 FOREST STREET 5/1/2017 Commonwealth Massachusetts
RECEIVED
�. Sy.Mem Pumping.Recordl
Y FQ
®EP has provided this form for userby local Boards of Health. er oM3 may be'used, but the
inforrnatlon must be substantially the carne as that provided here. Before using.this form,check with your
local Board of Health to determine the forth they use. The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information .
1. System Lo hon: Left/ ight'rf nt t f F o , Left/might rear of house, Left/right side of house, Left/
Right side of building, Llght fr6nt of buildid , Left/Right rear of building, Linder deck
Address
Citylrown State Zip Cotte
2. System Owner:
Name'
Address(if different from location)W
Cityrrown Stat C
Telephone Number
Pumpong Rpcord
1. Date of Pumping late 2. Quantity Pumped:
Gallons H� `"`♦
. Type-of system: Cesspool(s) ptic Tank `fight Tank
Other(describe):
4. Effluent Tee f=ilter present? Yes 01wo If yes, was it cleaned? E Yes El No,
5. Condition of System:
Al
6: System Pumped 6y:
Nell.Bateson - F5821
Marne vehicle License Dumber
Bateson Enterprises lnc�
Company
7. Lo do er ntents.were disposed:
.L Lowell Waste Water
sign Mule Date E
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