HomeMy WebLinkAbout- Septic Pumping Slip - 206 BOXFORD STREET 1/7/2019 Commonwealth of Massachusetts
w City/Town City/Town of
System Pumping Record
DEP has provided this form for use-by local Boards of Health. Other form 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 form they use.The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility Inform' ation
t. System Location: Left/Right front of Mouse, Left. ight�fmhous Left/right side of house, Left!
Right side of building, Left/Right front of building, Left/Right rear of building, finder deck
Address c �
_=�= o 0 &��
City/rown Mate Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town 5#ate• �( Q r Zip C,ode� /
'telephone Number
Pumping Rec
1. Cate of Pumping sate 2. Quantity Pumped: Gallons
3. Type-of system: E) Cesspool($) ptic Tank ® Tight Tanis
0 Other(describe):
4. Effluent Tee Filter present.? El Yes o If yes, was it cleaned? E Yes 0, No
5. Condition of system:
6. System Pumped 6y:
Neil.6ateson P5821
Name Vehicle License Number
e-455��t�
_6ateson Enterprises Inc
Company
7. Location where contents,were disposed:
Lowell Waste Water /
o.
Sign a Hhul Date
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