HomeMy WebLinkAboutSeptic Pumping Slip - 252 GRAY STREET 6/11/2018 Commonwealth of Massachusetts ME
" i own of
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SyMem Pumping,Record
DEP has provided this farm for use-by local Boards of-Health. Other forms maybe bsed, 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 to
the local Board of Health or other approving authority.
A. t InforMation,
1. System Location: Left/Right front of douse, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Riglit front of building, Left/Right rear of building, Under deck
Address 'A�
Cofrown State Zip Code
2. System Owner
Name'
Address(if different from location)
citylTown state Zip Codi
i 'telephone Number '�>
Pumping t .
1. Date of Pumping cafe �2. Qudnti Pumped: aiions3. 1'ype`af system: Cesspaal(s) t➢c Tank fight Tank
Other(describe):
4. Effluent Tee Filter present? Yeas o If yes, was it cleaned? ❑ Yes ® Na.
' S. Condition of System:
6: System Pumped By.,
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
�L S Lowell Waste Water _
Sign Dot
t5forrn4.doc-06103 system humping Record•Page 9 of 1