HomeMy WebLinkAboutSeptic Pumping Slip - 96 SUGARCANE LANE 5/22/2018 Commonweialth of Massachusefts
RECEIVEDClt�/Town of
y
Spm Me w r _018
®EP has provided this form'for use.by local Boards 'of Health. lather 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
the local Board of Health or other approving authority.
A. Facility, InforMati
1. system Location: Left/Right front of House, Left l Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address —A—C I
/
G
Zity/"rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City17'own State-
de
Telephone Number
Pqmpllng •Rqcord
1. hate of Pumping Date 2. Quantity Pumped: l `n
Gallons ,
3. Type-of system: El Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yeti 940 If yes, was it cleaned? Yes No,
' S. Condition of system:
6. System Pumped 6y:
Nei[Bateson - F6821
Name Vehicle License Number
l3ate�on Enterprises Inc
company
7. Location where contents-were disposed:
GL-SQ Lowell Waste Water
Si,gnAqe cf Houle Date
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