HomeMy WebLinkAboutSeptic Pumping Slip - 370 FOSTER STREET 12/26/2017 Commonwealth of Massachusetts
a
Cit Town of .
Otem Pumping.Record
Form
DEF'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 forma they use.The System Pumping Record must be submiiftpl t4
the local Board of Health or other approving authority.
A. Facility. Information .
1
1. System Location: Loft/Right front of house, Left I Right rear of house, Left/ l�ght �W_0_f_ho_u_s_,'E, Left/
Right side of building, Left/Right front of building, Left/Right rear cif building, Und
Address
.3 `
City/Town state Zip code
2. System Owner
I
Name
Address(if different from location)
City/Town State-
Telephone
tate Telephone Number
• � t w
. Pumping Kocord �
1. Date of PumpingDate 2. Quantity Pumped:
Gallons
3. Type-of system: E] Cesspool(s) is Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ® Yes El No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio"here contents-were disposed:
L Lowell Waste Water
,- e- - (7
Sign t fe_j HaulaV Date
15form4.doc•06/03 System Pumping Record.Page 9 of 1
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