HomeMy WebLinkAbout- Septic Pumping Slip - 2 ADRIAN STREET 3/4/2019 Commonwealth ®f Massachusetts
r
own of
SY.Stem Pumpingr
D P has providedthis form for use�by local Boards of Health. Other farms may be'used, but the
information-roust be substantially the same as that provided here. Before usin .this form,check with your
locc6l 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
t. System Location. Left/Right front of house, Left/Right rear of house eft F gh e o ouse left/
Right side of building, Left/Right front of building, Left/bight rear df bui ing, Url ep
Address � � «..��. +�.�•� r ��'
City/Town State Zip Code
2. System+Cwner.
Name
Address(if different from location)
City/Town State Z' Cp
�., ~ (= .
"telephone Number
Pumping cor
1. Cate of Pumping oats 2. Qudntity Pumped: Gallons
3. Type-of system: El Cesspool(s) 0 Septic Tank ® t Tank
ther(describe):
- � - - Ti1-��
4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? E Yes [I No
S. Condition System:
6. System Pumped By.,
Neil.Batesoq P5621
Name Vehicle License Number
Bateson Brit rises Ina
Company
7. Lo73"ILNS.:
ere contents-were disposed.
Lowell Waste Water
3
Sign a Hhule Crate
tftrm4.dooA 06103 System Pumping Record 4 Page 1 of 1