HomeMy WebLinkAbout- Septic Pumping Slip - 116 CHRISTIAN WAY 10/31/2018 Commonwealth of Massachusefts
C ity/T 3
own of Off 12018
System Pumpino Record �',OVER
or 4
DEP has provided this form for use-by local Boards of-Health. Other forms maybe`used,but the
information-must be substantially the tame 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 to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of house, Len 19 ar of housi,_ .eft/right side of house, Left I
Right side of building, Left/Right front of building,"CeigR1ghTr_ea_r6f_1�uiIding, Under deck.
Address
cityr rown "Skate W Zip Code
2. System Owner
Name*
Address Of different from location)
City/Town statee-1 Z' Code
Telephone Number
-13. Pumping Record
1. Date of Pumping Date 2. stun - Pumped: Gallons
7 c Tank
3. Type�of system: E] Cesspool(s) S epti Tank El Tight Tank
0 Other(describe):
4. Effluent Tee Filter present.? E] Yes 0 If yes, was 4t cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contenWwere disposed:
Lowell Waste Water
ignZe*Hmi Date— F
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