HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 675 FOSTER STREET 10/29/2020 Commonwealth of Massachusetts RECEIVED
kvCity[Town of
System Pumping Record' MT 2 1) � "(1)
HEA�JHDEPARTMENT
DEP has provided this form for use by local Boards of Health. Other formt may,boused,but the
irnformation,must be substantially the same as that provided here. Before using this kwm,check witty your
Board of Health to determine time tah they use. The System Pumping Record mast be submitted to
the local Board of Health or other approving authority.
A. FactfitY Informatlon
1. System Location: Left/Right front of house(
einhag. Left
Rlgt M�w , Left I right side of house, LeftRight side of building, Left/Right fr et of bui /Right rear of building, Under deck
Address
Etd
<
renown state Zip Code
2; System Owner
..._
Name'
Address(if different from y
CivTown Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua ntity Pumped: Gallons
3. Type of system: 0 Cesspool(s) ptic Tank Tight Tan
Other(descri'be).
4. Effluent Tee Palter present? Yes o if yes, was it cleaned? ❑ Yes El No
5. Con + o ,
- o
6. System Pumped By.
Name VeNcle,uoense Number
Bateson B' rises Ina
Copan
7. Location where contents were disposed:
Lowell Waste Water
Sign, Haulaf I Dater
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