HomeMy WebLinkAboutSeptic Pumping Slip - 103 BRADFORD STREET 7/18/2016 Commonwealth
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1 -Record
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DEP has provided this form for use=by local Boards of Health. Other for in'a jbi i 74u 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. aiii Info—rmation
I. System Left hfront rear o
Left/right side of house, Left/
9 ht side of bu Idingr Left gRig ht front of building, Left rear
of building, Under deck
Address
�. t
city/Town State Zip Code
2. System owner:
Name'
Address(if different from location)
Citylrown State _Zip Code
Telephone Number `d
. Pumping Rpcord
_ _ , v
1. Date of Pumping 2Cuantity Pumped: Gallons
Date
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ 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:
Lowell Waste Water
Si Haute —
g n a Date
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