HomeMy WebLinkAboutSeptic Pumping Slip - 144 SULLIVAN STREET 6/5/2017Corn onwealth of Massachusetts
City/Town of yste p ecord
4
DEP has provided this form for use.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. F. any informatiop
1. System Location: Left / Right front of house, Left
Right side of building, Left / Right front of building, Left / R
2. System Owner
7.70\
of house, left/ right side of house, Left /
rear Of building, Under deck
Address (if different from location)
City/Town
P
p
g ec
1. Date of Pumping
3. Type of system':
Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of Syst rri:
Date
•
Cesspool(s)
Zip Code
Telephone Number
2. Quantity Pumped:
Gallons
p ic Tank ID Tight Tank
If yes, was it cleaned? 0 Yes 0 No,
6. System Pumped By:
Neil Batesbn
Name
Bateson Enterprises Inc
Company
7. Locaijp erecontents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
t5form4.doo. OS/03 System Pumping Record • Page 1 of 1