HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 381 SUMMER STREET 12/12/2019 Commonwealth of Massachusetts RE 'SiVeD
City/Town of SEC 12 Z019
System Pumping Record �FNORINAND��ER
Form 4 00koL
�H DEPARTMENT
DEP has provided this form 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 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 Information
1. System Location: Left/Right front of hou g r f house Left/right side of house, Left
Right side of building, Left/Right front of bul ing, Left/Right rear build'ing, Under deck
Add ress a C U���—�— S �J( �� '�
City/Town State Zip Code
2. System owner:
Name'
Address(if different from location)
CdylTown Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping C C 2 Quanti Pumped:
Dam p Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E3 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System-/,."
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo w e contents-were disposed:
G L S Lowell Waste Water
sign a Haul Date
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