HomeMy WebLinkAboutSeptic Pumping Slip - 75 DUNCAN DRIVE 11/21/2017 Commonwealth of Massachusettsm E.�
City/Town of..
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SpOem Pumping.Record � , OF'p ,yzxll011MM6,
Foran 4
DEP has provided this form for use-by local Boards of Health. Other form's may be'used, but the
information,must be substantially the same as that provided here. Before using.this fomry,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted t® t
the local Board of Health or other approving authority.
A. Faculty lnformlatlon
9. System Location: Left/Right front of Hous , Left 4' igh� t h®usa,' Left/right side of house, Left/
Right side of building, Left/Right front of btil #rig, Left/Right rear of building, Under deck
Address
City[Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
cityrrown ' Sta# p Cade
F Telephone Number
f
. Pumping Rpcord
9. ®ate of Pumping nate 2. Quantity Pumped:
Gallons ;-
3. Type-of system: ❑ Cesspool(s) e
p tic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ Q If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Logia' n;O . re contents were disposed:
G L S.JQ Lowell Waste Water
Sign a I HbulerU bate
t5form4.doc*06/08 System Pumping Record•Page 9 of 1