HomeMy WebLinkAboutSeptic Pumping Slip - 52 NORTH CROSS ROAD 11/21/2017 C Commonwealth of MassachuseftsRECEIVED
_ .Cr Y/Town of
System Pumping.Record
Farm 4 HEAL -9 DEPARTMENT
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DEP has provided this forrri for use-by local Boards of Health. Other forms may•be'used,but the 1
information,must be substantially the same as that provided here. Before using.this form,check with your t
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.
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A. Facility Information
1. System Location: Left/Right front of Mouse, Left(ritight fe--ar of house; Left/right side of hawse, Left/
P Right side of building, Left/Right front of building;LWTRlght rear of building, Under deck
Address
CWrown state - Zip Code
Z. System Owner. /
Name'
Address(if different from location)
Cityfrown Sfat Zip Coda
( (
Telephone Number
t
. Pumping Record "
1. Date of Pumping bate 2. Quantity Pumped:
Cations ,.^ T
3. Type-of system: ❑ Cesspool(s) eptic Tank ® Tight Tank ,.
® Other(describe):
4.. Effluent Tee Filter present? ❑ Yes S-9,0 if yes, was it cleaned?
® Yes ❑ No.
` 5. Condition of System: LAI
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location whe.a contents-were disposed:
CLS: Lowell Waste Water
LPAUA
SigniWe cfHiaui Date
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