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HomeMy WebLinkAboutSeptic Pumping Slip - 180 GRAY STREET 8/16/2016 Commonwealth of Massachusetts _ City/Town of . RECEIVED S stem Pumping-Record ` Form 4 OF • y y�bVVtdd;b-'dF . DEP has provided this form for use. local Boards of Health. Other form's may 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 I. System Location: Left/Right front of house, Left I 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 cityrrown 1 State Zip Code 2. System Owner Name' Address(if different from location) CitylTawn State de , Telephone Number r 1 i .B. Pumping 1liecord .. 1. Date of Pumping bate 2. Quantity Pumped: -- Gallons 3. Type-of system: © Cesspool(s) eptic 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 7. Locati ere contents-were disposed: L ^ S: Lowell Waste Water Sign a I Haule bate t5form4.dor.-06103 System Pumping Record•Page 1 of 1