HomeMy WebLinkAboutSeptic Pumping Slip - 166 REA STREET 12/8/2009 Commonwealth of Massachusetts
City/Town of
- System Pumping Record
Form 4 C)VVIN OF M RI-H jaiv,0D�DVER
Di
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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 Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of hous 'rFit rear of"fiou . Left rear of building. Right rear of building.
--- ------------- - ------------ -
Address -
-
City/Town State Zip Code
2. System Owner:
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Name - -
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..............
Address(if different from location)
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City/Town State . Zip Code
Telephone Number
B. Pumping ec®r �.
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? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
- -- - y Frotem: _ - - - — - -
5. Condition ost�� �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locates-wr, contents were disposed:
G.L.S�D Lowell Waste Water
Signature of Hauler Date
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