HomeMy WebLinkAboutSeptic Pumping Slip - 112 STONECLEAVE ROAD 5/24/2017Commonwealth of Massachusetts
City/Town of
mp' e rd
yste
MA y' 2 4 ?Oi'/
TOWN NuH H ANUOVEa
HEALTH DEPARTMENT
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 yo r
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 / Right rear of housedePrigh c1;411(;$ ft /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Nen:19.
Address (if diffe
State
City/Town "
1. Date of Pumping
3. Type of system':
EJ
Date
Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? 0 Yea
" 5. Condition of System:
Telephone Number
Zip Code
2. Quantity Pumped:
Gallons
eptic Tank 0 Tight Tank
If yes, was it cleaned? LJ Yes 0 No,
0\c' 0,A) e ‘\ -VtAA1---c
6: System Pumped By:
Neil. Batesbq
Name
Bateson Enterprises Inc
Company
7. Locatrion here contents•were disposed:
77--;
S. Lowell Waste Water
F5821
Vehicle n Number
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