HomeMy WebLinkAboutSeptic Pumping Slip - 313 SUMMER STREET 6/1/2017p‘s
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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.
Com onwealth of Massachusetts
City/Town of
yste g ec rd
A. Facility IJnfor aflon
1. System Location: Left / Right front of house, Left/Fl4year of hou,se,1Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
2. System Owner:
Name
Address (if different from location)
City/Town
State z,
Telephone Numbe
P
p
g Reco
. Date of Pumping
2. Quantity Pumped:
Date Gallons
3. Type of system: 0 Cesspool(s) q—etsr:itic Tank ID Tight Tank
Other (describe):
4. Effluent Tee Filter present? El Yet Erkir If yes, was it cleaned? 0 Yes El No,
' 5. Condition of §`yste
6: System Pumped By:
Neit Bateson •
( lcAzk vv'
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S. Lowell Waste Water
F5821
Vehicle License Nu b r
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