HomeMy WebLinkAboutSeptic Pumping Slip - 42 BANNAN DRIVE 12/26/2017 omrrlanweal�th of Massachusetts
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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. Information
1. System Locahctn:'L O/Righ tont of Hou,ss Left/Right rear of house, Left/right side of house, Left/
Right side of building', Left/Rig�fifi 651 of building, Left/Right rear of building, Under deck
Address
CitylToum State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Stat Zip Code
'telephone Number
Pumping Record
1. Date of Pumping nate 2. Quantity_Pumped: Gallons
3. T e'of system.Yp Y. ❑ Cesspool(s) ❑--aeptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Ye.�; []-,No--- If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: MoJ-
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
?. Locafi)a. ere contents-were disposed:
G L S: 7Lowell Waste Water
Signitufe cf Haul Cate
t5form4.do(.-06/03 System Pumping Record•Page 1 of 1
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