HomeMy WebLinkAboutSeptic Pumping Slip - 30 GRAY STREET 11/17/2017 Commonwealth of Massachusetts
RECIVED
_ City/Town of ,m
� System P'-ump i ng.Recor � v
HEALU1 DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed, 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 r
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of Mouse, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address73
tom' 7A_ C �f� e, `✓. ti„1'�
Cityfrown state Zip Coale
2. System Owner
Name'
l
Address(if different from location)
City/Town State'
� Zip Code
p Telephone Number ;
T`
Pumping Record �.
9. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type�of system: El Cesspool(s) eptic Tank ❑ Tight Tank
El Other(describe): 1
4. Effluent Tee Filter present? Yes L.T e If yes, was it cleaned? ® Yes EJ No,
5. Condition of System
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises lnc
Company
• z
7. La tion w here contents-were disposed: 1
GL S: Lowell Waste Water
Sign a Hhuie Date F
if0rm4.doc-06/03 System Pumping Retard•Page 9 of 1