HomeMy WebLinkAboutSeptic Pumping Slip - 4 CHRISTIAN WAY 8/15/2018 Commonwealth of Massachusetts RECEIVED
Cit�/Town of AUG) 15 2018
a ` t • j Record 1,OWN OF��: iUHNDOV R
'm DEFIARTMEN'r
DEP has provided this fora for use-by local Boards bf-Health. Other forms may be'used, but the
information-must be substantially the same as that provided here. Before using.this fora,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submltte�d to
the local Board of Health or other approving authority.
Facility, Infor Mation
1. System Local L Rig o Q�hou Left I Right rear of house, Left/rightside pf house, Left./
Right side of b ` g, Left/Right rolding, Left/Flight rear of building, Under deck
• Address
Cityffown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' state `
r �rp�Code
A ,
Telephone Plumber
Pumping Record
1. Date of Pumping Cate 2. Quantity Dumped: Gallons w
3. Type-of system. ® Cesspool(s) ptie Tank Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? ® Yep o If yes, was it cleaned? F—) Yes ® No,
5. Condition of st ,mr. "j
`�.
i
6: System Pumped By:
Pfeil,Bateson 1"5621 l
Name Vehicle License Plumber
Bateson Enterprises Inc,
Company
7. Low' n contents-were disposed:
_ 7 S, Lowell Waste Water
-eigngtuhaqf KaulerU Date
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