HomeMy WebLinkAboutSeptic Pumping Slip - 61 ESSEX STREET 7/23/2018 Commonwealth f u n,
City/Town of
DEP has provided this formi for use�by local Boards 6f Health. Other forms may be'used,but the
information-must be substantially the tame 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.
I. System Location: Left/Right front of douse, Left 1 ht re f , Left/ri h l house, Left
Right side of building, Left 1 bight front of building, Left/Right rear of buildirl Under ec
Address
City/rown state Zip Code
2. System Owner.
I
Address Of different from location) 1
Cityffawn Stat ,
Telephone Number
h
1. Date of Pumping2. Quantity Pumped:
Date Gallons
3. `type-of systerni: ❑ Cesspool(s) eptic Tank (l Tight Tank t•
Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ® Yes 0 No,
5. Condition of first m•
6: System Pumped By:
Neil-Bateson ` F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7, Lo rg�
e contents,were disposed:
G 7Lowell Waste Water
Sign a rtuf Date
tMrm4.doo-06/03 System Pumping Record"Page 1 of 1