HomeMy WebLinkAboutSeptic Pumping Slip - 40 PHEASANT BROOK ROAD 6/6/2018 Commonwealth of Massachusetts
JUN t
�
Cit�/Town of
SY.4tem Pumping,Record
Form.
®EP ha'provided this form for use=by local Boards 6f Health. father 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 forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FactFactoty. I f t o
1. System Location: Left/Right front of house e l Righ l_r of house;Leff;/right side of house, Left
Right side of building, Left!Right front of building, Left/Right rear of building, Under deck
Address SVC)0 L
v
city/Town State Zip Code
2. System Owner: ,
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number r "w
i
. PquipingRecord
1. Crate of Pumping Ou
``� � 6ntity Pumped: )
Date Gallons �
r
3. Type-of system: ® Cesspool(s) Septic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes MINO if yes, was it cleaned? Yes No,
5. Condition of System:
JQ
6: System Pumped By:
Nell.Bates7on ' F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
C Sp Lowell Waste Water
Sign a Hauls Date
Mbun4.doc®06/03 System pumping Record page 1 of 1