HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 218 LACY STREET 9/22/2021 .�L\ Commonwealth of Massachusetts RECEIVED
City/Town of SEP 2 2 20?1
System Pumping Record T WNOFNORTHANDUVER
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Form 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/ fr nt of house, Left/Right rear of house, Left/right side of house, Left
Right side of buil I L /Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
�v «tip
Name
Address(if different from location)
CiWTown State ; C Zip Cod
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Zeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? �❑ No
5. Condition of System:
Uv
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location h re contentawere disposed:
Lowell Waste Water
SignAtule 9t Haul Date
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