HomeMy WebLinkAboutSeptic Pumping Slip - 54 VEST WAY 11/16/2017 Commonwealth of Massachusetts � wIVED
.Cityffown cif . Nil IJI V i Af 1210 1
System Pumping-Record
�`... Form
TOWN U �9ORI'i i A�tll��)VE
ij ,L�TiI DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may "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 t
the local Board of Health or other approving authority.
A. Facflity. Informi a#lon,
I. System Location: Loft 1 Right front of house,Right ear of hous ', Left/right side of house, Left/
Right side of building, Left I Right front of building, Left I Right rear of building, Under deck
Address
cityfrown State Zip Code
2. System Owner:
Name' 1
Address(if different from location)
City/Town Stat Zi
F _-- C,� p Code
Telephone Number
i
i
Pumping JRpcord
1. Gate of Pumping nate 2. Quanti Pumped: --=
Gallons ,.
8. Type-of system: ® Cesspool(s) eptic Tank Tight Tank
Other(describe):
4.. Effluent Tee Filter present? [] Yes o If yes, was it cleaned? F1 Yes No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo ,,iter contents-were disposed:
G L Lowell Waste Water
1- 7
Sign a Houle Gate
t5form4.doc•06/03 System Pumping Record•Page 7 of 1
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