HomeMy WebLinkAboutSeptic Pumping Slip - 11 PURITAN AVENUE 7/31/2017Commonwealth of Massachusetts
CRY/Town of .
System Pumping_ Record
Farm 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 forrn, 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, Facility Information
1. System Locatio 'Righ r rlt ref hou , Left/ Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address
Citylrown
2. System Owner:
State Zip Code
Name
Address (if different from location)
City/Town
Slate Zip Code
Telephone Number
.B. Pumping Record
1, Date of Pumping
Date 2. Quantity Pumped: Gallons 1.
3. Type -of system: ❑ Cesspool(s)_ eptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? ❑ Yeso If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition of System•
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Locaii s n here contents • were disposed:
Lowell Waste Water
F5821
Vehicle License Number
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