HomeMy WebLinkAboutSeptic Pumping Slip - 196 SUMMER STREET 12/5/2017 : Commonwealth of Massachusetts
_ City/Town o .
System Pumping-record
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DEP has 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, lnformiation a
1. System Locatio e !Rlgh rout of houLeft/Right rear of house, Left I right side of house, Left 1
Right side of buil g, Left 1 Right rant of buildirig, Left 1 Right rear of building, Under deck
Address q��
Cayfrown state Zip Code
Z. System Owner:
Name'
Address(if different from location)
cityrrown state- Zip Cotte
Telephone Number
B. PumpingRecord
1. Date of Pumping Date uantity Pumped: Gallons ! �
;/
3. Type-of system: [❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4•. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ Na
5. Condition of System:
jj
B. System Pumped By: uev--el
Neil.Bateson F5821
Mame Vehicle License Number
_Bateson Enterprises Inc,
Company
7. Lo where contents-were disposed:
CLS: Lowell Waste Water
SignAtufe H�vl ���~
Date
MorrM.dor.-06/03 System Pumping Record Page 1 of 1