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HomeMy WebLinkAboutSeptic Pumping Slip - 51 LONG PASTURE ROAD 4/13/2016 Commonwealth f Massachusetts Citffown of y yt m ' pin Form 4 �h kO 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. I r tiro I. System Location: LeftAght front crf Mouse;` .eft/Right rear of house, Left/right side of house, Left ip / Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityfrown State Zip Code 2. System Owner. Name Address(if different from location) City/,Town ' State Zip Code Telephone Number . Pumping IRecord €� 1. Date of Pumping sate 2. Quantity Pumped; Gallons tip 3. Type-of system: ❑ Cesspool(s) —8 ptic Tank ® Tight Tank ® Other(describe): 4. Effluent Tee Filter present? ©'Yes ❑ No If yes, was it cleaned? ❑`des ❑ No, ' 5. Condition of Syste ; 6: System Pumped By: Neil.Bates-on F5821 Name Vehicle License Number Batesan Enterprises Inc• Company 7. Locatiat wo re oontents were disposed: L S: 1 Lowell Waste Water SignAtufe cf Haute Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1