HomeMy WebLinkAbout- Septic Pumping Slip - 15 NORTH CROSS ROAD 8/28/2018 Commonwealth f u tt RECEIVED
i
s City/Town o
Pumpling.Record AUG 2 82018.
i..ii L a ii i �i.i ami n i:ENT
DEP has provided this form far use=by local Boards of-Health. Other forms may be'used, but the
information'roust be substantially the Same as that provided here. Before using.this fora,check with your
local Board of Health to determine the forr'n they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. 1'tInformation . 1
1. System Location: Left/Right front of House, Left/Right rear of hour h ids crf house Left/
Dight side of building, Left/Right front of building, Left/Right rear of building, Under&�q
Address -- w
Cityfrown State Zip Cone
2. System Owner.
Address(if different from Iooatlon)
CiVrown State , r Zip Code
"Telephone number +`
Pumpling Rpcord _ .
1. bate of Pumping Date 2. Qu' tjr Pumped: Gallons
3. Type-of system: Cesspools) eptiC Tank El Tight Tank
® Other(describe).
4. Effluent Tee Filter present? Yes No if yes, was it cleaned? 0 Yes ® No,
' 5. Condition of S+j+stem: � (J � � � ���������✓��-�--'
6: System Pumped By:
!Jell.Batesbn ' F6821
Name Vehicle License Plumber
Bateson Enterprises Inc'
Company j
7. Location W her. contents-were disposed:
G AHhUINU
Lowell Waste Water
r
' F
4Sign �I,t@
06rm4.doc°06/03 System Pumping Record"Page 9 of