HomeMy WebLinkAboutSeptic Pumping Slip - 2324 TURNPIKE STREET 6/10/2017 Commonwealth of Massachusetts
C4/Town of
y,4tem Pumping-Record
Form "
DEP has provided this form fo,r use-by local Boards of Health. Other forms maybe 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 forti7 they use.The System Pumping record must be submitted;to
the local Board of Health or other approving authority.
f
A. Facllity. Informlation
1, System Location: Left/Right front of house, Left I Right Arear aLeft I right side of house, Left f
Right side of building, Left/Right front of building, Left/ ght�rear cif build'�m Under deck
Address U � „
City/Town State zip Cotte
2. System Owner:
L'A ji-M
Name'
Address(if different from location)
city/Town ' state•�TRZip Code
CC
Telephone Number
P
. Purnping Rgcord
1. Cate of Pumping date 2• Quantity Pumped:
Lallans ,.^"—"•
8. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ other(describe):
4.. Effluent Tee Filterresent? '�
p ® Yes if yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
6. System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Ehterprises Ince
Company
7. Loca' here contents-were disposed:
C L S: Lowell Waste Water
SignAture Ct HauerDate
5form4.doca 06/03 System Pumping Record•Page 1 of 7
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