HomeMy WebLinkAboutSeptic Pumping Slip - 112 COLONIAL AVENUE 12/4/2017 Commonwealth of Massachusetts
Ci"t�ffo1Jt n of
r i
y teM Pumping.Record
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DEP hes provided this form for use=by local Boards of Health. Other forms may be'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.
A. Facility. Informi ation .
1. System LocatioRig t of house Left/Right rear of house, Left/right side of house, Left 1
Right side of bui ` g, Left/Right fronto buildifig, Left 1 Right rear of building, Under deck
Address 11 L "`
City/'rown State Zip Code
Z. System Owner.
Name'
Address(if different from location)
City/Town Sfate,;.� .e ,�„ � Code ;
Telephone Number r`s
Pumping Ketcord }�
1. ®ate of Pumping2. Quantity Pumped: -----t
Date Gallons
3. Type-of s stem: -�
Yp Y. ❑ Cesspool(s) � p� t'rc Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of Sy em: „�� (� SZ)v 1, "C
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises lnc,
Company
7. Location where contents-were disposed:
C Lowell Waste Water t
SignMcfl bate
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