HomeMy WebLinkAboutSeptic Pumping Slip - 70 BROOKVIEW DRIVE 6/1/2017 Commonwealth of Massachusetts
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Pumping.Srkem OIOVM c u t
Farms MPAMMEW
DEP has provided this form`for use=by local Boards of Health. Other forms may `used, but the
Information must be substantially the tame as that provided here. Before using.this farm,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.
Facflity Information.
I. System Location: Left/Right front of douse, Le lght rear of hou ,.Left/right side of house, Left/
§ Right side of building, Left I Right front of building, a tghr of building, Under deck
Address .
city/Town State Zip code
. System Owner
Itz� . ,
Name'
Address(if different from location)
citylrown ' state rhe -
4
t Telephone Plumber d '=
P
Pumping
I. Date of Pumping Date . u !3tity Pumped: Gallons�
t-W "
3. Type-of system: Gesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? [_j Yep,- No If yes, was it cleaned? Ej Yes 0 No,
' 6. condition stent
✓� Kealk"_,,
\
6; System Pumped By:
Nell.Bateson P5621
Dame Vehicle License Plumber
Bateson rwterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
ISIgneHoule Date
t5formet.doo-06/03 system Pumping record•Page 1 of 1