HomeMy WebLinkAboutSeptic Pumping Slip - 878 WINTER STREET 8/21/2017 Commonwealth of Massachusetts NO
CHY/Town of
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DEP has provided this farm'for use.by local Boards of Health. father forms may'be'used, but the
Information•must be substantially the same as that provided here. Before using.this form,check with your J
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.
. r
A. Facility. Information r
1. System Location: Ce"– ig crit-f h ua s,deft/Right rear of house, Left/right side of pause, Left/
Right side of building, Left at-ef- ilidiriq, Left/Right rear if building, Under deck
Address • ,i _
CiWTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State
�� 4 o Zi de
t l'
Telephone Number
Pumping R�%,cord
1. Cate of Pumpingbate . Quantity Pumped: Canons —=-c
8. Type-of system: ❑ Cesspool(s) Q- e5` ptic Tank ❑ Tight Tank y
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No,
• v , f
5. Condition of System:
kl/00
— c'�
..
....
6.. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number 1
Bateson Enterprises Inc,
Company
7. Location where contents were disposed:
L
e-
S-P Lowell Waste Water
F
SignAtufe qt HgulerU Date
t5form4.doc-06/03 System Pumping Record.Page 9 of 1