HomeMy WebLinkAboutSeptic Pumping Slip - 151 STONECLEAVE ROAD 5/22/2018 Commonwealth Massachusetts
Cjt�/Town of
K. d 2 LY M
. C ' Record4IX X &. /
01,
DEP has provided this form'far use-by local Boards bf Health. Other farms may be'used,but the
lnformetion�must be substantially the sarne as that provided here. Before using.this form, check with your
la l Board of Health to determine the forrh they use.The aystem Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. it , Inforiffl' ation
t. System Location; Left/Right front of Mouse, Left/ t mar of hausel Left, right side of house, Leff/
Right side of building, Left/Right front of building, Left/R g real of building, Under deck
Address
cityrrown State Zip Code
2. System Owner.
Name*
Address(if different from location)
Ciwrown Stat �- r •- t-Code
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Qucintlty Pumped:
Cate Gallons
3. Type-of system: El Cesspool(s) Septic Tank [l Tight Tank
[� Other(describe):
4. Effluent Tee(Filter present? ® Yes No If yes,was it cleaned? ® Yes El No,
5. Condition of Sy tefn: 4 '�°,'�-,���:=..�.
6: System Pumped By:
Pfeil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo `a/n'w here content.%were disposed:
Lowell Waste Water
Sign Hhulwutate
tftnn4.doc-06/03 System Pumping Record a mage 1 of 1