HomeMy WebLinkAbout- Septic Pumping Slip - 137 CHRISTIAN WAY 10/2/2018 Commonwealth of Massachusetts
QtKown of
K)rhI Hf p,k qC)OVEW
DEP has provided this form for use:by local Boards o*f Health. Other forms may be used,but the
information•must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted tc t
the loom Board of Health or other approving authority.
A. FaciRty. Inform'of on
1. system Locatio • 'I ig r 'it pf hou Left/Right rear of house, Left/right side of house, Left
Right side of but ' g, Left I Right front of building, Left/Right rear of building, Under deck
AddressCxA
r^
Cityltown State ( Zip Code
2. System Owner: L, i` •
Name
Address(if different from location)
Cityrrown ' stat Zip Code
'telephone Number �,
.B. Pumping ftecord
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type•of system: E] Cesspool(s) eptic Tank El Tight Tank
® Other(describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned? 0 Yes ❑ No.
5. condition of tcc
6. System Pumped 6y:
Neil,Batesbn F562.1
Name Vehicle License Number
_ ateson Enterprises Inc
Company
7. Lo "o'n' a contents were disposed:
G L S: Lowell Waste Water
Sign i�iule Cate
t5forrn4.4lo 06/03 system Pumping Record Page 1 of 1