HomeMy WebLinkAboutSeptic Pumping Slip - 137 BRIDGES LANE 4/24/2018 u ,') a
Commonwealth of Massachsetts
City/Town of AM. " ,4 2018
Tsymem Pumping.Record (
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DEP has provided this form for use-by local Boards 6f-Health. Other forms may be'used, but the
information-must be substantially the same as that provided Dere. Before using.this form,check with your
local Board of Health to determine the fora they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facloty. Information
r
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear df building, Under deck
Address
City/rown ( state Zip code
2. System towner:
Namur'
Address(if different from location)
Ci frown stater
s `telephone Number
ID
t
,B. Pumping
t
s
. peord
1. Gate of Pumpingnate 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspooi(s) 0-Septic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yep Ido If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of system: V �--
6: System Pumped By:
Nell.Bateswan F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents-were disposed:
.L S; Lowell Waste Water
1.5
sign a Fieul Date
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