HomeMy WebLinkAboutSeptic Pumping Slip - 10 TUCKER FARM ROAD 8/23/2017 RECEIVED
Commonwealth of Massachusetts
x w C4/Town of AUG 1.
System Pumpin .Record TOWNOFNMHANDOVM
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DEP has provided this form for use-by local Boards Health. Other forms may be'used, but the
information,must be substantially the tame as that of provided here. Before using.this form, '
heck 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
I. System Location: Loft!Right front of Mouse, Left/ i rear ofius , Left/right side of house, Left/
Right side of building, Left/Right front of building, eft/Right rear of building, Under deck
Address
City/rown State Zip Code
7. System Owner: )
Name`
Address(if different from location)
City/Town ' State' / CCade
f 'telephone(Number r `'
I
• Pumping Rpcord
J7
1. Gate of Pumping Date �• Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe); r...
4.. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na:
5. Condition of System:
pe��
c l -
6: System Pumped By:
Nell.Bateson - F5821
Name vehicle License dumber
Bateson Enterprises Inc
Company J
7. LocaUs.
contentswere disposed:
G Lowell Waste Water
rSign Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1