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HomeMy WebLinkAboutSeptic Pumping Slip - 40 SUGARCANE LANE 9/6/2016 :.C- Commonwealth of Massachusetts a C4/Town of : c NORTH N�) v :F�Z y,S rip - i LiH FAF4 r MEN F a. Form 4 DEP has provided this form for use-by local Boards of Health. other form's 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 I. System Location: Left�ight front of ho su 4)Left/Right rear of house, Left/right side of house, Left/ Right side of building, LeCgh t o building, left/Right rear of building, Under deck . Address City/Town State Zip Code 2. System Owner. Name' Address(if different from location) cityfrown ' Stater Zip Code t &q`S_ It Telephone Number i B. Pumping Ripcord ct 1. Cate of Pumping oat . 2. uantity Pumped: � _ Gallons 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 ' S. Condition of System: Z Ulf, 6: System Pumped By: Neil.Bates-on F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: ., C L S; Lowell Waste Water r signAtule fHgule Date f t5farm4.doc•06/03 System Pumping Record•Page 1 of 1