HomeMy WebLinkAbout- Septic Pumping Slip - 481 REA STREET 1/8/2019 Commonwealth f Massachusetts
w City/Town of
System rv. Pumping
Former 4 ,
DEP has provided this farm for use by local Boards of health. Other forms may be'used, but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local ward 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 douse, Left&§fft rear of 6 se, Left/right side of house, Left
Right side of building, Left/Flight front of building, Left/Right rear of building, Under deck
Address
Cityr o State Zip Corse
2. System Owner. � ( /
(h,Av\-eL l
Name'
Address of different from location)
City/Town State Zip Code
(4 C�' ( - -Zk a
`telephone Number
Pumpling Kecord
1. Date of Pumping Date C l 2. ( unfity Pumped:
Gallons
3. TypeW system: E] Cesspool(s) Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yes �/No if yes, was it cleaned? Yes No
5. condition of System:
6, System Pumped By:
Nell Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatioarw re content were disposed:
S Lowell Waste Water
Sign a Flaul Cate
tftrm4.doc•06/03 System Pumping Record.gage 1 of 1