HomeMy WebLinkAboutSeptic Pumping Slip - 178 BRIDGES LANE 12/14/2017 : Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
Foam 4
DE-p has provided this form for use-by local Boards of Health. Other form's 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 farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inforn�a#ion
1. System Location: Left/Right front pt house, Leff/Right rear of house,(Qlprlght " e of h e, Left
Right side of building, Left 1 Right front of building, Left 1 Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTawn Stated t Zi ap�not
;
Telephone Number + 4
3 i `
t
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons i
3. T pe•of System'.
Y ❑ Cesspools} eptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L' ' o if yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati a contents-were disposed: M
G Ir S. 7 Lowell Waste Water
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F
Signitufa I HwlwU Date
06rm4.doe-06103 System Pumping Record-Page I of 1