HomeMy WebLinkAboutSeptic Pumping Slip - 124 SAW MILL ROAD 11/21/2017 Commonwealth of Massachusetts RECEIVED
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S item Pumping.Record �6 :��r �
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DEP has provided this farm for use-by local Boards of Health. Other forms maybe`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.
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A. Facility Information
1. System Location: Left/Right frodt of house,��ei� Rigvire;Clif
ar""o�hovs� Left/right side of house, Left!
i
Right side of building, Left 1 Right front of buitd'lt Lef 'rear of building, Under deck
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Address
City/Town state dip coke
2. System Owner:
Name'
Address(if different from location)
City/Town ' State- de
F c.
Telephone Number f
Pumping Rpcor -0_7
9. Cate of Pumpingdate 2. Qua tity Pumped: "ter
Gallons
3. Type-of system: ❑ Cesspool(s) ' Septic Tank ® Tight Tank
® tither(describe):
4. Effluent Tee Filter present? Q Yes LD-M-6- If yes, was it cleaned? ® Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Batesbn - F5621
Name Vehicle License Number
Bateson Enterprises Inc•
Company
1. Location where contents-were disposed:
CLS. Lowell Waste Water
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t5form4.doc•06103 system Pumping Record•Page 1 of 1