HomeMy WebLinkAboutSeptic Pumping Slip - 48 SUNSET ROCK ROAD 5/22/2018 Commonwe.althof Massachusetts
City/Town of MAY 2 2 2018
eSp4tem Pumping.Record Form rowti,10p,TjNiXWER
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DEP has provided this form-for use>by local Boards of Health. Other forms maybe used,but the
information-must be substantially the same as that provided here. Before using.this form *
heck with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility information
1. System Looation:(Ce /Righ rpn of house, eft I Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Rigl fry'n o uildirig, Left/Right rear of building, Under deck
Address tic ,
uklSf
City/Town State Zip Code
2. System Owner:
Name'
Address Of different from location)
cityfrown ` State Zip Cade
Telephone dumber
b t ,
i
® Pumping Rpeord �
1. bate of Pumping2. u-ntity pumped: -----�
Date Gallons �r
r
3. Type-of system: ElCesspoul(s) Septic Tank Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes /No If yes,was it cleaned? EJ Yes ❑ Na.
5. Condition of P}rstem:
VVI 6,
6; System Pumped By:
Nell.Bateson F5321
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locatio ere contente,were disposed:
L S Lowell Waste Water
E
Sign a Hhuie Cate
lMrm4.doca 06/03 System lumping Record.Page t of 1