HomeMy WebLinkAbout- Septic Pumping Slip - 175 OLD CART WAY 10/2/2018 Commonwe alth of Massachuseffs
wCity/Town of
i SyMem Pumping.Record
'vowrl OF
DEP has provided this form far use-by local Boards of Health. Other forms may be'used,but the
Information-must be substantially the game 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 f®
the local Board of Health or other approving authority.
A. Facill.ty Inn r fl
1. System Location: Left/Right front of douse, Lett/Right rear of house, Left/ri h side of hous , Left
Right side of building, Left/Right front of building, Left/Right rear of building, Un ec
Address
City own State Zip Code
2. system Owner:
Name'
Address Of different from location)
City/Town Scat� ���I � •,�o�d®� ,
R I J
"telephone Plumber '
` I
.B. Pqmping !Record
i
—� � -
1. Date of Pumping 2. Quonti!y Pumped:
Date Gallons x.
3. Type-of system: El Cesspool(s) eptic Tank light'Tank t
Ej Other(describe):
4. Effluent Tee Filter present? ® Yet o If yes, was it cleaned? ® Yes El No, j
S. Condition of System:
6: System Pumped By:
Neil.gatesion F5821
Name Vehicle t lcense Number
Bateson Ehterprises Ina
Company J
7. Locati9; here contents-were disposed:
//S"": �� Lowell Waste Water
F
Sign a i�bol Date
lftrrn4.docd 06/03 System Pumping Record d Page 1 of 1