HomeMy WebLinkAboutSeptic Pumping Slip - 1620 TURNPIKE STREET 7/13/2016 Commonwe'alth of Massachusetts
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It�/Town of
System Pumping,Record
Form 4•
D►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 house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown ' -§t at Zip Code
Telephone Number
i
. Pumping Rpcord �
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) - 1Wglc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p El Yes af4,0 If yes, was it cleaned? E] Yes ❑ Na
5. Condition of System: �
6. System Pumped By:
Neil.Bates®n • F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location
..where contents were disposed:
G L S- Lowell Waste Water
Sign [efkauleiU Date
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