HomeMy WebLinkAboutSeptic Pumping Slip - 197 VEST WAY 5/1/2017Common ealth of Maisachusefts r,
City/Town of
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DEP has provided this form for usaby 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 informati
1. System Locatio Rig
Right side of bthfdifl, Left / TkiijM16Wf buflding, Left / Right rear of building, Under deck
Left / Right rear of house, Left / right side of house, Left /
Address
City/Town
2. System Owner:
Name.
Address (if different from location)
City/Town
. Date of Pumping
. Typeof system':
0 Other (describe):
Date
Cesspool(s)
4. Effluent Tee Filter present? El Yea
' 5. Condition of System:
Stat
Zip Code
2. tiy Pumped:
Gallons
ptic Tank Ei Tight Tank
If yes, was it cleaned? 1:3 Yes El No,
uit_ \ (A,
6: System Pumped By:
Nell Bateson •
Name
Bateson Enterprises Inc
Company
7. Lo contents were disposed:
Lowell Waste Water
F5821
Vehicle License Nurnber
Sign e Haule Date
t5form4.doc• 06103 System Pumping Record 0 Page 1 of 1