HomeMy WebLinkAboutSeptic Pumping Slip - 623 OSGOOD STREET 9/12/2016 Commonwealth of Massachusetts
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System Pumping. Record
Form 4
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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 Inform' ation
1. System Location; Loft�Rig- rant of house 1 aft 1 Right rear of house, Left/right side of house, Left/
Right side of building, L:a t-Rig6t1ront'a buiidirig, Left/Right rear of building, Under deck
Address
D--3 6 : .
City/Town State Zip Code
2. System Owner.
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Name`
Address(if different from location)
Cityfrown ' State Zip Cade
Telephone Number +' .
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye, o If yes, was it cleaned? ❑ Yes ❑ No,
' S, Condition of Systerr��
6: System Pumped By.,
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S: Lowell Waste Water
T 1 4 ' A
tO . .
,.
-Signgtq to Fihule Date
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