HomeMy WebLinkAboutSeptic Pumping Slip - 125 SHERWOOD DRIVE 12/2/2015 Commonwealth of Massachusetts
_ City/Town of
System Pumping-Record 1
Forth 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 I tght. mnt_of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
"a... ,.,
City/Town State Zip Code
2. System Owner:
1
Name'
Address(if different from location)
Ci /Town
'ty States „�•� ��.` .w
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons ,-
3. Type-of system: ❑ Cesspool(s) ❑-septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System: " , vv
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatipmWhere contents were disposed:
Lowell Waste Water
OA
Sign a Haule Date
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