HomeMy WebLinkAbout- Septic Pumping Slip - 546 SHARPNERS POND ROAD 11/26/2018 Commonwealth of Massachusetts RECEIVED
City/Tow nip\1 2 6 Z 0 1�1
System Pumping Record ER Form 4 1 1
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DEP has provided this form for use-by local Boards of Health. Other forms maybeused, but the
informatl=must be substantially the tame 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: Left/Right front of house, Left/Right rear of house, Left. I
Right side of building, Left Riglit front of building, Left/Right rear of buIldfng,'EFnde_r_d4`qW--
7 Address -A
cityfrown -State zip code
2. System Owner:
Name'
Address(if different from location)
cityfrown ip?o
Telephone Number
.13. Pumping Record
1. Date of Pumping Date2. Quantity Pumped: Gallons3. Type-of system: El Cesspool(s) a-g_e�pficTank D Tight Tank
[I Other(describe): .............
4. Effluent Tee Filter present? C] Yes B-N-o-_" If Yes, was it cleaned? El Yes El No
5. Condition of System
6. System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Local":Vh7re contents-were disposed:
Lowell Waste Water
C,
Sign a Date
WbITM.doc-06103 System Pumping Record a Page 1 of 1