HomeMy WebLinkAboutSeptic Pumping Slip - 46 HOLLOW TREE LANE 4/24/2018 Commonwealth of Massachusetts � '°�
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SyMem Pumping-Record
Form
®EP has provided this farm 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 forrh they use. The System Pumping Record must be submitted to fi
the local Board of Health or other approving authority.
A. Facloty. Inforlihatlon
1. System Location: Left/Right front of house, Left/Right rear of house, efts lgh 0 of haus _ Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CIWTown State Zip Code
2. System Owner: uAn
Name'
Address(if different from location)
cityrrown State;, Zip Code
fry r7 / 1
Telephone Number E`y
Pumping Record �
1. Cate of PumpingDate 2. Quantity Pumped:
Gallons i.
3. T pe•of s stem: ='
Type-of system'*. ❑ Cesspool(s) ' eptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ❑ Yes ® No,
y
6. Condition of Sy tem:
.. .
. ,
6. System Pumped By:
Neil,Bateson • F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
L S Lowell Waste Water
' f
SignAtule I Haute Date
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