HomeMy WebLinkAboutSeptic Pumping Slip - 66 EQUESTRIAN DRIVE 6/6/2018 Commonwealth of Massachusefts ' "
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M.a TOWN OFNM
DEP has provided this formfor use=by local Boards of Health. Other forms maybe bsed,but the
information-must be substantially the tame as that provided here. Before usin .this faun,check with your
local Board of Health to determine the form they use.The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
1. System Location: Left/Right front of house, igi�t r of hou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address l #
�.r
City/rows State Zip Code
2. System Owner:
Z\Ul.
Name'
Address Of different from location)
Cityrrown " Stat Zi de
'telephone Number r'
Pumping_ car
(�c --
1. Date of Pumping fiat 2. Quantity Pumped:
Gallons N
3. Type-of system: El Cesspool(s) 0-Septic`tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes c o If yes, was it cleaned? ® Yes El No
5. Condition ofSystem:
rLL � �
6. System Pumped By:
Nell.Batesbn - F6821
Name Vehicle License dumber
Bateson Enterprises Ina
Company
7. Loca'® content&were disposed:
C L S Lowell Waste Water
F
1110,
Sign a 'Hauls Date
t5form4.doo•06/03 System Pumping Records page 1 of 1