HomeMy WebLinkAboutSeptic Pumping Slip - 205 GRAY STREET 7/11/2016 Commonwealth
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S item Pumping. Record
YS
4
Form 4
DEP has provided this form'for useoby local Boards 'of Health. Other forms m, �a 4 Rtsi?etit linformation must be substantially the same as that provided here. Before usinhl rlith your
local Board of Health to determine the form they use.The System Pumping Record fitted to
the local Board of Health or other approving authority.
A. Facility, Information .
1 Right side of bui ` g Left/ rohoof hour U;Left/Right rear of house, Left/right side of house, Left/
System 9
lding, Left/Right rear of building, Under deck
Address `
f"m
Cityfrown o-~' State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town C
State � Zip Code
� r
Telephone Number
i
. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Lallans
3. Type-of system: ❑ Cesspool(s) ptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o 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
e h re contents-were disposed:
7. Locatio _
(�t Lowell Waste Water
Sign a Haute Date
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