HomeMy WebLinkAboutSeptic Pumping Slip - 499 WINTER STREET 4/11/2016 Commonwealth of Massachusetts
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City/Town Of
Pumping-S item YS
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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/Right front 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
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cltyfrown - State Code
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Tele hone Number
a
B. Pumping Rpcord
1. Date of Pumping pate 2. Quantity Pumped: Gallons y--`
3. Type-of system: ❑ Cesspool(s) ❑-Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yap ❑moo..,,.,.. If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
� .
6: System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lacati
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whre contents were disposed:
L S. Lowell Waste Water
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SignAtu I Fe ct Haule Date
t5form4.doc•06/03 System Pumping Record m Page 9 of 1