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HomeMy WebLinkAboutSeptic Pumping Slip - 49 CARLTON LANE 5/24/2017CE Com onwealth of Maisachusefts City/Tow of 2 ?ow yste PH phi eci rd TowNur NIUK V1 ANUOVER HLALTii DEPARTMENT DEP has provided this form. for us&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. Information 1. System Location: Left / Right front of house, Right side of building, Left / Right front of bui / Right r of ho).eft/ right side of house, Left / , Left / o uilding, Under deck Address 49 6. a City/Town 2. System Owner: rA, r- rl a P, ov\ei, Al /I State Zip Code Name' Address(if diffrent from lo n) City/Town P pin cor 1. Date of Pumping 3. Type.of system': Other (describe): State Telephone Number Zip Code S---20 /7 ©U 2. Quantity Pumped: Date Gallons Cesspool(s) dSeptic Tank 0 Tight Tank 4. Effluent Tee Filter present? 0 Yes E3/N0 " 5. Condition of System: 1 / -cv\-e,/ If yes, was it cleaned? Ej Yes LI No, 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Lo on-vtih re contents were disposed: Lowell Waste Water F5821 Vehicle License Number Sign Heule W Date Wormtday 06/03 System Pumping Record Page 1 of 1