HomeMy WebLinkAboutSeptic Pumping Slip - 55 BRADFORD STREET 6/27/2016 Commonwe.alth of Massachusefts 'RECEIVED
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System Pumpin§-Record
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Form 4 rOWN OF F,
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®EP 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 hous ft/Rig>twre f houses Left/right side of house, Left/
Right side of building, Left/Right front of birig, Left/Might`°.F65r of building, Under deck
Address -sue' 7
City/Town State Zip Code
2. System Owner:
C
Name'
Address(if different from location)
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Zip
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C� /Town ,
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Telephone Number
Pumping Record
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1, Date of Pumping Date 2. Qu tity,Pumped: canons
3. Type of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes a 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
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where contents were disposed:
7. Lacatt
jSigne � Low ell Waste Water
Haute Date d
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