HomeMy WebLinkAbout- Septic Pumping Slip - 52 NORTH CROSS ROAD 1/8/2019 Commonwealth of Massachusetts
City/Town of
System Pumpong Record
For 4
DEP has provided this form for use-by local Boards of Health. Other forms may beused,but the
inform a. don-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 tc)
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./right side of house, Left I
Right side of building, Left Right front of buildirig, Left/Right rear of building, Under deck
Address
C>C:)-
Cityfrown state Zip Code
2. System Owner
Na►ne'
Address(if different from location)
CltyfTown Stat%-- Z* Co
C
Telephone Number
.B. Pumping Kocord
1. Date of Pumping Date ;�2. Qu6nti Pumped: Gallons
ep�
i
le Tank
3. Type-of system: El Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? 0 Yes glwo If yes, was it cleaned? E] Yes ❑ No
6. Condition of System:
6. System Pumped By:
Neff Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loqatitm contents-were disposed:
G, S.M� Lowell Waste Water
Sign
Houle
ig e H Date
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