HomeMy WebLinkAboutSeptic Pumping Slip - 45 GRAY STREET 8/1/2016 : Commonwealth of MassachusettsM
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System Pumping.Record
Form 4
DEP 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 fnfolrm' ation
1. System Location: L RI ht of�ho ue, Left 1 Right rear of house, Left!right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear df building, Under deck
Address
CRY/Town State - Zip Code
2. System Owner:
Name.
Address(if different from location)
city/Town ' State Zip Code
Telephone Number
y - f
.B. Pumping Kecolyd t
1. Date of Pumping Date 2. Quantity Pumped: Gallons �r
3. T e•of s stem: ;
yp y• ❑ Cesspool(s) � eptic Tank El 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:
Nell.Batesan -- F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo aHiiule ontents were disposed:
G S. Lowell Waste Water f
Sign Date
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