HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 39 GRANVILLE LANE 4/23/2020 :&\ Commonwealth of Massachusetts RECEIVED
City/Town of A,PR 212020
System Pumping Record TOWN C)FNUKtHANt)uv,ER
Form 4 hE,LTH DEPARTMENT
DEP has provided this form for umby local Boards of Health. Other forms may 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 authorlity.
A. Facility Information
1. System Location: Left/ t rant of lion Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig ront of building, Left/Right rear of building, Under deck
Address '� CJ u �W e ��
Wrown state Zip Code
2. System Owner.
Name
Address(if different from location)
Cityf Town State Tip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date2. Quantity Pumped: Mons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑_Ym-f"'No If yes, was it cleaned? '❑ No
5. Condition of,System-
-6
tz�-
6. System Pumped By.-
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
_ S Lowell Waste Water
signitwe qt Haulmu Date
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