HomeMy WebLinkAboutSeptic Pumping Slip - 101 FOSTER STREET 12/4/2017 Commonwealth of Massachusetts
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System IP-umpini .Recordl .�,� , �.
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DEP has provided this farm for use-by loco!Boards of Health. ®they forms maybut 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.
A. Facility Information
1. System Location: Left/Right front of house, Leftl Right rear of hour ,... /right deaf house Left I
Right side of building, Left/Rigl t fr6nt of building, Left/Right rear of building, Under deck
Address _
City/Tawn state zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State, Zip Cade
F Telephone Number
I
Pumping Rpmcord
1. Cate of Pumping —I r7 t 2. uantity Pumped: —
Bate 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,
' 5. Condition of System:
lloodej
6. System Pumped By: i
Neil Bateson F5821
Name Vehicle License Number
Bateson Ehterprises ince
Company
7. Locatin where contents-were disposed:
C L S Lowell Waste Water
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sig—niture Ct Haul Cate
t5farm4.doc•06/03 system Pumping Record•Page 1 of 1