HomeMy WebLinkAboutSeptic Pumping Slip - 242 LACY STREET 11/21/2017 Commonwealth of Masseohusefts
IVED
Z y
Ciiy/Town of ���������C ��n�
System Pumping.Record
�'l ALI i& tip G'�,C�°�"�r� 6,t°�
DEP has provided this form'for 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., '
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.
f
A. Facility InforMation
1. System Location: Left I i ht front t�f f7ous , Left I Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
city/Town State Zip Code
2'. System Owner,
Name
Address(if different from location)
Cityrrown State Zi d
Telephone Number
f
y
. Pumping Record
1. Bate of Pumping Date 2. Quantity Pumped:
Gallons �c
3. Type-of system' '
yp y. � Cesspool(s) eptic T na k � Tight Tank
® Other(describe):
f
4. Effluent Tee Kilter present? ® Yes o If yes,was it cleaned? M Yes [] No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821 �
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location,;e7
ontents�were disposed:
CLS: Lowell Waste Water
1.7
F
sign a Haul Date
t5f6mi4.doc•06103 System Pumping Record•Page 1 of 1