HomeMy WebLinkAboutSeptic Pumping Slip - 186 INGALLS STREET 12/4/2017 Commonwealth of MassachusettsRECEIVED
Cityffown of .
Sy tem P!umping.' Record �q �
Form � � � 1 ��� ���I��u a �IlH
.XWE1
DEP has provided this form far usenby 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 t
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. FaCH ty Inform' ation
1. System Location: Left/Right front of houseEgo),
Rig ear f ;Left/right side of house, Left/
Right side of building, Left/Right front of b�tLeft/Ri ht rear of buildin Under deck
9 g 9 g g.
Address
Cityfrown state - Zip Code
2. System Owner:
Name•
` ` f
Address(if different from location) 1
CitylTown ' Stater -7
- ..,Zip Cade ;
Telephone Number t�
• � � 4
. Pumping ping Recordr ' " ,.
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ es ❑ No if yes, was it cleaned? Yes ❑ No,
' 5. CondiC"t C
tion f stem:
6. Sys em Pumped By:
Nei[Batesbn F5821
Name Vehicle Ltcense Number
Bateson Enterprises Inc
Company
7. Lo tiol-1- re contents-were disposed: 1
Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 9 of 1
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