HomeMy WebLinkAboutSeptic Pumping Slip - 190 BRIDGES LANE 7/22/2016 : Commonwealth of Massachusetts
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System Pumping.Record , Q
Form 4
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DEP has provided this form for use-by local Boards of Health. Other forn in" 66"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 forum they use.The System_ Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. InforriatIon
1. System Location: Left 1 Right front of house ig re�6�fihouseL--,,eft-I right side of house, Left I
Right side of building, Left/Right front of bui i�eft 1 iUnder deck
Address
cayfrown State - Zip Code
2. System Owner.
Name'
Address(if different from location)
citylrown ' Statei, LfL�35 ;
f Telephone Number1.
9
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.B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type,of system: ❑ Cesspool(s) ptic Tonic ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E3-g if yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
1�J � t %JA ��
6: System Pumped By:
Neil.Batesan ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
company
7. Lo ti re contents-were disposed:
G L S. Lowell Waste Water
SignAtufe HaulleV Date
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