HomeMy WebLinkAboutSeptic Pumping Slip - 56 CRICKET LANE 11/28/2017 Commonwealth of Maisaohuseffs
CitY/Town of
System Pumpiln§.RecordForm 4
M
DEP has provided this form 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 forma,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted tca
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left I Right front of house]-_14 Y R'tgh rear of house;."Left.I right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner. -
Name'
Address(if different from location)
Cityrown ' State- zip Code
f 6
Telephone Number
r
.B. P'umping JRpcord
1. Date of Pumping ( Quantity Pumped: -
Date Gallons
3. Type-of system; ® Cesspool(s) Septic Tank [] Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes No If yes,was it cleaned? ® Yes ® No
6. Condition of System:
6. System Pumped By:
Neil.BatesonF6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
l
7. Location where contents-were disposed:
C L S: Lowell Waste Water
XrcSA 9 FU_
Sign a Hiaule Date
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