HomeMy WebLinkAboutSeptic Pumping Slip - 112 FOSTER STREET 12/4/2017 ID
Commonwealth of Massachusetts
_ City/Town of
SOtE'm Pumping-RecordForm 4
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j
DEP has provided this form€or 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 form,check with your j
local Board of Health to determine the farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Informlation .
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address w
1 .iDL
CitylTown state Zip Code
2. System Owner.
Name*
Address(if different from location)
City/Town ' State r ( .Ziprdo
G
Telephone Number
. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank j
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System•
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo .oaawhere contents-were disposed:
CLS: Lowell Waste Water
Sign a Hauie Date F
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