HomeMy WebLinkAboutSeptic Pumping Slip - 249 CARLTON LANE 6/6/2018 Commonwealth Massachusetts
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DEP has provided this form'for use-by local Boards 6f Health. Other forms l ay be•used, but the
information-trust be substantially the same as that provided hare. Before using.this form,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.
A. Facility. Information
1. System Location: Left/Right front of house, Left�Rrg&-r-eai�of hotas. , Left/right side of house, Left f
Right side of building, Left/Right front of buildingIght rear of building, Under depk
Address
City own State Zip Code
2: System Owner:
Fame'
Address(if different from location)
Cityfrown ' Stater c Zip Code
Telephone Number `
Pumping Record
1. Date of PumpingDate A7' Septfic
uantity Pumped:
Gallons
3. Type•of,system: Cesspool(s) Tank ® Tight Tanis
Other(describe):
.4. Effluent Tee Filter present? Yep WNo If yes, was it cleaned? ® Yes ❑ NQ
' S. Condition of System:
6: System Pumped By:
Neil.Bateson F6821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Locati where contents,were disposed:
G L S Lowell Waste Water
S,I,9 nAtute Pmu&UCate E
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