HomeMy WebLinkAbout- Septic Pumping Slip - 1620 TURNPIKE STREET 5/1/2019 m
Commonwealth of Massachusefts
fi
Uty/Town of
Systetn, Pumping Record
Porm,
1�.
DEP has
p_rovilded this form ,,by local Boards,of,Health'. f rmt;may,be'used,,but the
information,must be substinflallythe tame as that provided �r . Before UsIng.this form,check with your
10CM Board of Healthdetermine the forts they use. TheSystemPumping Record must be submitted to
the local Board of Health or other approving author .
A. Facility
rear', I..Le
building,Right side of iRight buildin
h
Address
Vll�
CRY/Town, state Zip Cody
Owner.2., System
Name
Address(if differerit from locaflon)
Cirm,
Telephone Number
,,,
Pumping Record
. Date of Pumping 2. Qfi
bate Gallons
3. Type-of system: Cesspool(s) n EJ Tight Tank
0, Other escr :
Filter,4. Effluent Tee Y If yes, was it c Yes E] No
5. CondMon of System:
System0:) N,
6.
Nell.
Nanne Vehicle License r
Bateson
Company
were -,
Lowell Waste Water
p�
1
Sig F Hhul I °
t oPumping