HomeMy WebLinkAboutSeptic Pumping Slip - 87 SUGARCANE LANE 5/22/2018 IVED
. Commonwealth of Massachusetts R�����`'�
C4/Town of
SY.4tem Pumping-Record TOWN OF Iqo:�EH ANDOV MA
FOrft'1I 4
T&I DODAKIMHIT
DEP has provided this form 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 tri
the local Board of Health or other approving authority.
A. Facility inforMation
y
1. System Location: Left/Right front of house, Left fight r of boos Left/right side of house, Left/
Right side of building, Left/Right front of building, e /Right rear of building, Under deck
Addressf
`'
City/Town �7i� - state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown state- Zi Code ;
Telephone Number
r
. Pumping Record .�
-
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
8. Type,of system. [l Cesspool(s) eptic Tank El Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? ® Yep B-No if yes, was it cleaned? n Yes ❑ No
6. Condition of System:
�)o
rAAc .
6. System Pumped By:
Neil.Bateson 1=5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
CLS: Lowell Waste Water
F
SignAt4e f Haule Date
t5form4.doc•06/08 System Pumping Record•Page 1 of 1