HomeMy WebLinkAboutSeptic Pumping Slip - 80 CHRISTIAN WAY 4/24/2018 Commonwealthof Massachusetts
i
I Record
Sy.4tem Pumping
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DEP has provided this forth for use-by local Boards of Health. tither forms may be'used,but the
information,must be substantially the same as that provided here. Before uing.this form,check with your
local Board of Health to determine the forth they use. The System pumping Record must be submitted tc:
the local Board of Health or other approving authority.
A. acflity. I f rMation
1. System Location: Left/Fight(rant of house, Left Rr h�of ; Left'I right side®f house, LeftRight side of building, Left/Fight front of building, building, Under deck
Address y}
A
Cityfrawn � t - Stere ��
(y atle
2. System Owner:
Address(if different from location)
cityfrown ' Mate Zip Cade
`telephone htumb r
Pumping cr 0 ell �
1. Gate of Pumping c ;�/Qu6naity CaPumped:Date pons 3. Type of system: ElCesspool(s) SepticTnk Tight Tank
® Other(describe):
4. Effluent Tee'Filter present? Ej Yes No If yes,was it cleaned? Yes No,
5. Condition of Systerp:
6; System Pumped By:
Neil.Satesan ''5821
Mame Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio where contents-were disposed:
G_ S: Lowell Waste Water ( //
$19n a Hhule Cate 6
t5form4.doc*06103 System Pumping Record•page 1 of 1