HomeMy WebLinkAboutSeptic Pumping Slip - 86 BROOKVIEW DRIVE 5/1/2017Comma wealth of Massachusetts
City/Tow of. •
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DEP has provided this form for useby 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 ation
1. System Location: Left / Right front of hous
ear thoue_, Left / right side of house, Left /
Right side of building, Left / Right front of b'tiItdUi, Left / Right rear of buiIdingUiiJer decjsf
2. System Owner:
Address (if different from tocation)
City/Town
P
gRe
rd
1. Date of Pumping
Date
3. Type of system":
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
. Condition of Syste :
State I
Telephone Number
2. Quantity Pumped:
Cesspool(s) E9 optic Tank
pp Code
"45
Gallon
0 Tight Tank
6: System Pumped By:
Neil Bateson
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S. Lowell Waste Wate
Sign fibula
If yes, was it cleaned? 0 Yes 0 No
WA-) (kecuu,
F5821
Vehicle License Number
Da
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