HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRADFORD STREET 12/4/2017 Commonwealth of I4o ssaohusetiS o
City/Town of
.
SOtem Pumping-Record
d
DEP has provided this form for use-by local Bodrdl3 i -lealth. Other form's may be'used, but the
information,must be substantially the same as that provided here. Before using.this form,check wi#h your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to l
the local Board of Health or other approving authority.
A. Facill.ty. Information
1. System Locatio n >/RighCfront of ho , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/R@h MIront of building, Left/Right rear of building, Under deck
Address r
Citylrown state Zip Code
2. System Owner: 7 j
Name'
Address(if different from location)
City/Town ' State- Zip Code
Telephone Number r
t
B. Pumvetping ,Record
1. ®ate of PumpingDate 2. uantity Pumped: �-�
Gallons H
3. Type-of system: El 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:
6. System Pumped By:
Nell Bateson - F5821 t
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed: 1
CLS: Lowell Waste Water i
— F
Sign a Houle Date
l5form4.doc-06/03 Sys+