HomeMy WebLinkAboutSeptic Pumping Slip - 180 GRAY STREET 9/7/2017 Commonwealth of Massachusetts
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Sy.�tem Pumpin§- tecord TOWN OF t
Form HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the
lnformati=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.
A. Facility Information .
1, System Location: Left/Right front of house, Left] 'tght rear of houLeft/right side of house, Left/
Right side of building, Left/Right front of building, Le/Right rear of building, Under deck
9 9
Address
(,q_ b �j .. .....
Cityrrown State - Zip Code
2. .System Owner:
Name'
Address(if different from location
CitylTown State-
Telephone Number
r
Plumping Racord
1. Date of Pumping Date 2. fWuantlty Pumped: Gallons -
3. Type-of system: ® Cesspool(s) [DSeptic Tank [j Tight Tank s
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes N-b If yes, was it cleaned? [D Yes ® No,
5. Condition ofrrt�m
6. System Pumped By:
Nell.Batesbn - F5821
- Name Vehicle License Number
Bateson Ehterprises Inc-
Company
7. LocafiolLwhere contents-were disposed:
GLS: Lowell Waste Water
` ._ r
Signitufe I HaulerU Date
t5form4.doe•06/03 System Pumping Record=Page 1 of 1