HomeMy WebLinkAbout- Septic Pumping Slip - 55 STONECLEAVE ROAD 1/8/2019 Commonwealth of Massachusefts
City[Town of
System Pumping Record
For 4
DEP has provided this form for use-by local Boards of Health. Other forms maybeused, but the
information-must be substantially the-tame as that provided here. Before using,this form,Check with your
loc*il 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 InforMatlon
1. System Location: Lek/Right front of house, Left/Right rear of house, Left./right side of house, Left I
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
I........... ..........
City/Town State Zip Code
2. System Owner
Name'
Address Of different from location)
City/Town stater Zip Cod
---
Televpone Number
.13. Pumpling Record
1. Date of Pumpingpate 2- Quiinft Pumped: Gallons
3. Type-of system: E] Cesspool(s) El-�epfic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? E] Yes M--90 If yes, was it cleaned? 'El Yes F-1 No
5. Condition of Systern-
6. System Pumped By:
Nell.Batetbn F5821
Name Vehicle License Number
Bateso i Enterprises Inc
Company
7. L o cafi contents-were disposed.,
7r(�- S-77 Lowell Waste Water
--0 f
Sign Haul Date
tSfbrm4.dor,-06/03 System Pumping Record Page 1 of 1