HomeMy WebLinkAboutSeptic Pumping Slip - 784 WINTER STREET 9/1/2016 : Commonwealth of Massachusetts
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City/Town of RECEIVED
System Pumping-Record I ?W
Form 4
I'OVq OF
DEP has provided this form far use;by local Boards of Health. Other forms may�e 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
1. System Location: Left/ ht front of hous , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ron o uildirig, Left/Right rear of building, Under deck
. address
City/Town State Zip Code
2. System Owner.
Name`
Address(if different from location)
city/Town own ' State<� .,, v 0 de
p Telephone Number T +J
i
B. Pumping JRecord �
1. Date of Pumping Date 2. Quantity Pumped: Gallons`
3. Type-of system: ❑ Cesspool(s) eptle Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-N0 If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of System: 9
6. System Pumped By:
Neil Meson F5821
Name Vehicle license Number
Bateson Enterprises Inc-
Company
7. Loca` contents-were disposed:
C L S:J Lowell Waste Water
Sign a —HauleV Date
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