HomeMy WebLinkAboutSeptic Pumping Slip - 123 MARIAN DRIVE 6/6/2018 �,.J
Commonwe.althOf Massachusetts
City/Town JUN 0
Q$ ?018 ofIpI(f pry
Sy.4tem Pumping.Record TOMfOFl"+1CJI'�IN-IP41,C \\E-J:"'
Porta 4
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DEP has provided this fora for use-by local Boards of-Wealth. Other forms may •used, but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Wealth to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facill.ty. InforMation
1. System Location: Lift/Right frpnt of Mouse, Lei/ 'ht raa us± , Left/right side of house, Left 1
Right side of building, Left I Right fr6nt of building, Left ght rear df building, Under deck
Address
CiWrown _ state Zip code
2. System Owner:
Name'
Address of different from location)
CitylTown ' state �E�J '� � ! // _Zip
p Lk..� c
"telephone Number
i
Pumping Record
� -—•
9. ®ate of Pumping pate 2. Quantity Pumped. Gallons
3. Type-of system►: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter presents es ❑ No if yes, was it cleaned? es F—I No,
5. Condition ofyst�
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle Llcense Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
MLSrP Lowell Waste Water
II/ cSA
E
S€gn A fi�e kauia I bate
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