HomeMy WebLinkAboutSeptic Pumping Slip - 337 PLEASANT STREET 8/15/2018 Commonwealth of Massachusetts RECEIVED
Citj /Town of
_ sy.'tern Pumping-Record AUQ' 1 1
Farm 4 � � r�40P�u � .
[EA1'Ili E� NAl�'1 i_iiT
DEP has provided this form for use-by local Boards oMeelth.Other forms may be'used,but the
information,must be substantially the,same as that provided here. Before ustng.this farm,check with y�ur
local Board of Health to determine the form they use.The System Pumping Record must be submitte to
the local Board of Health or other approving authority.
A. Facility. information
1. System Location; Left/Right front of house,
Left/Right rear of hous>s, eft fight l house L ft
Right side of building, Left/Right front of building,Left/Right rear of but ding, Un e
Address
1 State Zip code
cityrrown
2. system Owner:
Name'
I
Address Of different from location)
cityrrown ' Stater` ✓ " r }P
Telephone Number( �7 "� 'moi
1, Date of Pumping bay 2- Quantity Pumped: Gallons -----
3. TypeW system: ❑ Cesspool(s) eptic Tank ❑ Tight Tante
❑ Other(describe): f
4. Effluent Tee Filter present? ❑ Yes ^ 0 -. if yes,was it cleaned? [} Yes ❑ Na
G
'S. Condition of system:���
6. system Pumped By:
NellBatesbn ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
?. Lo re contents-were disposed: _
pli
Lowell Waste Water
Sign Date
iform4.dor.-06103 System Pumping Record Page 1 of 1�