HomeMy WebLinkAboutSeptic Pumping Slip - 10 TANGLEWOOD LANE 6/5/2017Commonwealth of Massachusetts
City/Town of .
yste eco d
Fo 4 -‘01
DEP has provided this form for use4)y 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.
Facility I
formatio,
1. System Location: Left/ Right front of house, Left ht rear of house:left./ right side of house, Left /
Right side of building, Left / Right frOnt of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Narne.
Address (if di
tion)
City/Town
State. --
v4) 0 6-
Telepane Number
p
g Re
0
1. Date of Pumping
3. Type -of system:
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of Syste
6; System Pumped By:
Nell. Bateson •
Name
Bateson Enterprises Inc
Company
Date
Cesspool(s)
7. LacationJier contents were disposed:
Lowell Waste Water
Sign Haule
2. Quantity Pumped:
Gallons
eptic Tank 0 Tight Tank
If yes, was it cleaned? 0 Yes El No,
F5821
Vehicle License Number
Date
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