HomeMy WebLinkAboutSeptic Pumping Slip - 80 PHEASANT BROOK ROAD 1/12/2016 ommonw Ith of Massachusetts
k City/Town of .
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System Pumping.Record
Farm 4 t
DEP has provided this farm 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, Left ht rear"us�, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state _ .Zip Code
° a
2. System Owner:
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Name
Address(if different from location)
Citylrown State-
• .��°'' °�� ��`C Code
Telephone Number r
P
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type-of.system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'1140 If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System•
6: System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
v-S: Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1