HomeMy WebLinkAboutSeptic Pumping Slip - 695 MASSACHUSETTS AVENUE 11/17/2015 : Commonwealth of Massachusetts
_ City/Town of .
System Pumping-Record
Form
4
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 house(tef(Y Righ ear of house ft•/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rlg�t rear of building, Under deck
Address R 1
City/Town State Zip Code
2. System Owner. ),
Name G
Address(if different from location)
city/Town State- Zip Code ;
' 7''7
Telephone Number f
B. Pumping Record �..
1. Date of Pumping Date i I P 2.�Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
El Other(describe): ' �ez` Co
4. Effluent Tee Filter present? ❑ Yep ® No If yes,was it cleaned? ❑ Yes ❑ No:
5. Condition of System:
0 V"A
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Lioense Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
G L S. Lowell Waste Water
SignAhfe 9t Haule Date
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