HomeMy WebLinkAbout- Septic Pumping Slip - 60 TIFFANY LANE 10/19/2018 .sL Commonwealth of Massachusetts
City/Town of 9v �'a
A System Pumping Record
Form 4 0V,5jMFqf
DEP has provided this form for use>by local Boards of Health. Other forms may beused, but the
informadon-must be substantially the same 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 to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Leh htfrontofhouse eft/Right rear of house, Left./right side of house, Left I
0;s�
4C:! ' u
Right side of building, Left/Rig r-6-n o uildifig, Left I Right rear of building, Under deck
Address
LjA
city/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrow" star, Z' de
Telephone Number
® Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: E3 cesspool(s) e_p_Vc,Tank [I Tight Tank
[3 Other(describe):
4. Effluent Tee Filter present? El Yes 3-ko if yes,was it cleaned? Yes No
6. Condition of Syste
6. System Pumped By:
Nell.Bates7on F5821
Name Vehicle Utcense Number
Bateson Eriterprises; Ina
Company
7, Location where contentsrwere disposed:
M. Lowell Waste Water
Sign e Haule Date
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