HomeMy WebLinkAboutSeptic Pumping Slip - 10 PURITAN AVENUE 11/21/2017 VD
Commonwealth of Massachusetts ��E � �� ��'�
_ CVTown of
b..
Li ^
Form HLl..��.� :
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,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: Loft/Right front of house klj��igr ofhou . eft/right side of house, LeftRight side of building, Left/Rigt t front of bui dlhg, el F ear of building, Under deck
Address Vu
City/Town State Zip Coale
2. System Owner;
Name'
Address(if different from location)
Citylrown State p Code
P Gil 4L
Telephone Number ` w>
® P'iuimpoing Rpcor
1 .7
1. Date of Pumpingnate 2. Quantity Pumped; ---{
Gallons �
3. Type-of system'; ❑ Cesspool(s) fic T nk ❑ Tight Tank
(� tither(describe): -
4. Effluent Tee Filter present? ❑ Ye,,s E9--146if 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. L eation•e here contents-were disposed:
CLS: Lowell Waste Water
Sign a Haul Date
t5formCdoe•06108 System Pumping Record•Page 9 of 1