HomeMy WebLinkAboutMiscellaneous - 205 GRAY STREET 8/18/2015 Commonwealth of MassachusettS RECEIVED
City/Town of Fmk ` 0 °
YS to Pumping-Record ord iti
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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 j
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio . Le Righ ant of hous ,Left/Right rear of house, Left./right side of house, Left/
Right side of bui mg, Left/Right front of building, Left/Right rear of building, Under deck
1
Address 1
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ' Sta p4ip de
Telephone Number
B. Pumping Record �..
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem: / \ ^�4
6: System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
Gy LS. Lowell Waste Water
Sign a 9t Haule Date
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