HomeMy WebLinkAboutSeptic Pumping Slip - 167 GRANVILLE LANE 6/14/2017 Commonwealth of Massachusetts
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S stein Pumping.RecordPA
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DEP has provided this form for use=by local Boards of,Health. Other forms may b ed,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.
1
A. Facllify, Information
1. System Location: Loft/Right front of house, Le Ri h rt a=house Left/right side of house, Left/
Right side of building, Left/Right front of buildirig, Left/Right rear of building, Under deck
Address
Cityf"rown 79tate Zip Code
2. System Owner:
Name'
Address(if different from location)
City/'rown State �,, Zip Code
Telephone Number +`
B.Pumping ping JRecord11-7
1. Date of Pumping "/2./2. Quantity Pumped:
Gallons
3. Type-of sys.temQ Cesspool(s) e tic Tank ❑ Tight Tank j.
❑ Other(describe):
4. effluent Tee Filter present? ❑ Yes o if yes,was it cleaned? Q Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
.LSQ Lowell Waste Water
r
Sign a qt HbulerU Date
0orm4.doob 06/03 System Pumping Record•Page 1 of 1