HomeMy WebLinkAboutSeptic Pumping Slip - 287 FOREST STREET 3/22/2016 Commonwealth of Massachusetts
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System Pumping-Record MA
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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
the local Board of Health or other approving authority.
A. Facility. Infor ati n
1. System Location: Left/Right front of house, Left/Right rear of houseCLeftPr ig l e of house, ft/
Right side of building, Left/Right front of building, Left/Right rear of building, Uncle°f-d
Address (,A4
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown ' State Zi�Cod
Telephone Number �^
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B. Pumping record r
1. Date of Pumping 2. Quantity Pumped:
ate Gallons
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3. Type of system: ❑ Ce ool(s) a tic Tank ® Tight Tank
ther(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No:
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5. Conditiolp of Sys tem:
6: System Pumped P: Z�v
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca` where contents were disposed:
G L Lowell Waste Water
Sign a I Haule Date
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