HomeMy WebLinkAboutSeptic Pumping Slip - 45 HOLLOW TREE LANE 5/24/2017Comm° wealth of Massachusetts
City/Tow
ystem ping ecor
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DEP has provided this form for uselv local Boar0`..-; ilillhi;thuevrElfOrms may be used, but the
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information must be substantially the same as that provided here. Before using.thls 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 11
1. System Location.
Right side of buil
2. System Owner:
Warne"
ft/ Right rear of house, Left/ right side of house, Left /
o?irfbuildirig, Left / Right rear of building, Under deck
Address (if differentdiffernt from ocation)
City/Town •
ping
1. Date of Pumping
. Typeof system':
0
Date
Cesspool(s)
0 Other (describe):
Sta t
Telephone Number
2. Quantity Pumped:
(6
Gallons
ptic Tank 0 Tight Tank
4. Effluent Tee Filter present? 0 Yep
Condition of System
If yes, was it cleaned? 0 Yes [11 No,
or diked Geitii(
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio re contents were disposed:
Lowell Waste Water
Sign e. Hau
F5821
Vehicle License Number
Date
t5form4.doo. 06/03
System Pumping Record Page 1 of 1