HomeMy WebLinkAbout- Septic Pumping Slip - 312 FOSTER STREET 6/24/2019 F "EIVED
Commonwettith of Massachusefts
Uty/Town of
1 r
��"�'�x a. ilill'..' yIu�'WIM UIDIDUV H��yl�uw�wri � J i� N �System Pumplbg RecordW
oD09 k ENT[":X
Form 41
DEP
1
f
has provided this ford for us ,�by local Boards of,Health. Other formis may beuse,d, but the
Information-must be ashy the tame as that provided here. Beforesl .th,is form,check with your
ical Board of Healthto determinethe for" they use. TbeSystem Pumping Record must be submitted to
the local Board of Health or other approving authority., 1
�t
X, Facifloty
InforMation
go" T!q I. System Location: ig ront of ouise Left I Right of
r H
Righti i r i , w reck
Ad dress
-K
2 1 11111"N - ..........-----------------
own state Zip Code
2. System Owner.
1
1
Name*
Address(if different from l a
Telephone Number ;r
1
.B.
u
u N
Pumping
l Record
. Date of PumpingDate2. Pumped: ..................
Type-ofGallons
3. y0�,Semr�lclDT'Igh nk
1
(descrlbe)-
4. Effluent Tee Filter present? Yes If yes, was it cleaned? ET Yes N
6 Condition of Systems
V\
1
t
frr
1
. System Pumped y
Nell.Bates7on F5821'
Narne Vehicle Ucense Number
Bateson ri
Inc-
company
. Location wheren
Lowell Waste!Water
IeON
S Ig lie Hat
I HAularu Date
Mbrm4.doce 06/03 System Pumping ,