HomeMy WebLinkAboutSeptic Pumping Slip - 240 GRAY STREET 7/2/2018 Commonwelafth of MassachuseftsRECt
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SyMem Pumping,
a i IEALT H DEP 1,TMENT
CEP has provided this form`for use-by local Boards bfflealth. Other forma may be'used,but the
information must 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. fl , InforMation
1. System Location: Le./Right front of house, Left I Rlght rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
_ T
City/rown state Zip Code
2. System Owner: ' j
Name'
Address(if different from location)
CitylTown ' Stafe,6�7
. � i
Telephone numberID
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® Pumpling Record
1. Date of Pupping Date 2. Quantity Pumped:
Gallons w
3. Type-of system': ® Cesspool(s) eptic Tank ❑ Tight Tank
❑
Other(describe):
4. Effluent Tea Filter present? E] Yes o if yes, was it cleaned? ® Yes ❑ No,
6. Condition of System:
sIn C�s
6. System Pumped By:
Nail.Bateson - F5821
Larne Vehicle License Number
Bateson Ehterprises; Inc-
Company
7. Location wcontents-were disposed:
MLS-07 Lowell Waste Water
Sign Houle Date
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