HomeMy WebLinkAboutSeptic Pumping Slip - 427 SUMMER STREET 6/11/2018 Commonwe'alth of Massachusefts
RECEIVO
CiWrown of
SY,4tem Pumping.Record
I,.i°EM 6 K,i wheel k..°6eE'�
DEP has provided this form for use-by local Boards of Wealth. Other forms rnay'be'used, but the
Information-roust be substantially the same as that provided here. Before using.this forret,Shenk 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. Fact0ty,
1. System Location: Left/Right front of dousedgmIL'aft
gh ear -hous Left/right side of house, Left/
Right side of building, Left I Right front of bu / rear of
building, Under deck
Address �J �,�1..�1✓�.. Q�''��` y �� •-•--0p;,IL -..`"`
CRY/Town state Zip Code
2. System Owner:
Name'
Address of different from location)
Cityfrown ' Zip Code
Telephone Number
i
• i
Pqmping Record
1. bate of Pumping Date 2. Quantity Pumped: Gallons r
3. Type of system:
Cesspool(s) ( ea'` pt Tank Tight Tank
Other(describe):
4.. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? ® Yes [I No,
5. Condition of System
p..."'.
6. System Pumped Ey:
Nell.Bateson ' F5821
Name Vehicle License Number
_Bateson Ehte rises Inc'
Company
7. SeHaulal
contents-were disposed:
Lowell Waste Water
Date `
t5form4.doo°08103 System Pumping Record d page 4 of 1