HomeMy WebLinkAboutSeptic Pumping Slip - 32 BANNAN DRIVE 5/22/2018 Commonwealth of Massachusetts
4 ii
Cjt�/Town of
MAY 2, Z 2018G
KA04 01A
DEP has provided this forldfor use.by local Boards®f Health. tither forms may be'used,but the
information,must be substantially the tame 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 roust be submitted to
the local Board of Health or other approving authority.
A. d Inform' ation
1. System Location: Left/Right front of house, Le i ht�ear of haus. , Left/right side of house, Left/
Right side of building, Left/Right fr®nt of building, Left g of building, Under deck
Address
67d_Yr own State Zip Code
2. :System Owner: "
Name
Address Of different from location)
City7"rown State `1 rip code ;
A
'telephone Number
--------------
f
Pumping i i
Si
1. Cate of Pumping 2. Quantity Pumped: ---�----' -r
. Date Gallons
3. 'Type-of system: El Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
. Condition of System:,' .f
6.• System Pumped By:
Neil.Bates7bn ' F5821
Name Vehicle t_icense Number
Bateson Enterprises Inc
Company
7. o = e contents-were disposed:
L S Lowell Waste Water
' F
Sign a Raul Date
t5form4.doca 06103 System Pumping Record d Page 1 of 1