HomeMy WebLinkAboutSeptic Pumping Slip - 261 BRIDGES LANE 11/7/2017 RECEIVED
Commonwealth of Massachusetts
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C!tY/Town of NOV7 70 I
System Pumping.Recor TOWN ONOl�TIIANDa R
y'
Farm HEALTH DEPARTMENT
DEP has provided this form far 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 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/Right rear of house, e ' igh-�a cif u e,1,eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
Address
c4frown State Zip Code
2. System owner:
Name'
Address(if different from location)
Cityfrown State Z de
b
Telephone Number �3
. Pumping Record
1. ®ate of Pumping nate Z Quantity Pumped:
Gallons
3. Type-of system`: ❑ Cesspool(s) epti Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent.Tee Filter present? ❑ Yes o If yes,was it cleaned? ® Yes ❑ No,
5. Condition of System:
1
6: System Pumped By:
Neil Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
1
7. Lo ion ere contents-were disposed:
1,ZGLS: Lowell Waste Water
slgn a Haule Date
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