HomeMy WebLinkAboutSeptic Pumping Slip - 1060 TURNPIKE STREET 8/17/2016 Commonwealth of Massachusetts RECEIVED
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System Pumping.Record &-
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DEP has provided this form for use=by local Boards of Health. Other forms may be bsed, 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(O Rlgh ,rp t of house Left/Right rear of house, left/right side of house, Left/
Right side of building, Left/Right fron o building, Left/Right rear of building, Under deck
Address "
a,
c"rty'iown State Zip Code
2. System Owner.
Name` 4 ,✓
Address(if different from location)
City/Town ' State- ZIP
s Telephone Number r"
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
date Gallons i------"`
3. Type-of system: ❑ Cesspool(s) ®"'Septic Tank ❑ Tight 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.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca#iornl re contentar were disposed:
C L AHaule Lowell Waste Water
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Sign fi Date
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