HomeMy WebLinkAboutSeptic Pumping Slip - 371 SUMMER STREET 11/28/2017 Commonwealth of Massachusetts
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u 4/Town of
S �toml Pumping-Record
Form 44 k a
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IEP has provided this form for user 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 t®
the local Board of Health or other approving authority.
A. Falcifity Information
1. System Location: Left/Right fro tat of hous Le Right ar ofi house, Left/right side of house, Left
Right side of building, Left/Right front of bui trig, Left/Right rear of building, Under deck
Address c,
City/rown state Zip Code
2. System Owner: )
i
Name'
1
Address(if different from location)
City/rown ` Stag , /"'y" Zip`�Co�dg
Telephone Number
ti Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons ,r-
3. Type-of system: ❑ Cesspool(s) ept Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yep ❑ Nom If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste
6; System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
?. Lo tionrtaere contents-were disposed:
G S: Lowell Waste Water
. f
SignAture fHiule Gate
0arm4.doc•06103 System Pumping Record d Page 9 of 1
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