HomeMy WebLinkAboutSeptic Pumping Slip - 1080 TURNPIKE STREET 5/17/2016 jL Commonwealth of Massachusetts
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System Pumping.Record.
Form 4
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. Sy ht side Location:I /e g c r t nt. .", Left/Right rear of house, Left/right side of house, Left/
ti h r�..' of hous '
R f L ft/Ri'hf fro µofti"uildin , Left/Ri ht rear df buildin Under deck
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Address
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Cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown ' State
• �� � �" � 4 Code ;
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Telephone Number
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B. Pumping Record �
1. Date of Pumping pate C 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ❑" Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yes ❑ No If yes, was it cleaned? E] Yes ❑ No
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-Where contents were disposed:
'"CLS-Q Lowell Waste Water
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Sign a Haule Date
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