HomeMy WebLinkAboutSeptic Pumping Slip - 357 REA STREET 12/13/2017 Commonwealth of Massachusetts
Cjty/Town o .
System Pumping-Record
Farm 4
DEP has provided this form for use-by local Boards of Health. Other form's maybe'used, but the
in€ormation,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. Inform' ation
1. System Location: Left/Right front of douse, Left 1 Right rear of nous vrc 'lgh side of haus eft 1
Right side of building, Left 1 Right front of building, Left 1 Right rear of ulldtn , Under deck
9 9 9 9
Address _
Jam'
Cityfrown States Zip Code
2. System Owner.
Name'
Address(if different from location)
Cltyfrown - State y��`S--1� .3jp Code
Telephone Number
.B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes leo If yes, was it cleaned? ❑ Yes ❑ No,
' 6. Condition of st m:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehte rises Inc-
Company
7. location where contents-were disposed:
G
LS". Lowell Waste Water
p
' f
SignAtufe cf HiaulleV Date
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