HomeMy WebLinkAboutSeptic Pumping Slip - 475 FOSTER STREET 9/15/2016 Common wealth of Massachusetts
City/Town of .
i /St tl1 Punlp117� Record
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. ... . . . Form 4 a '
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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. Facii%ty. Information
1, S y stem Location: Left/Right front at house
,(LefI;- Rlg ar hmse`, Left/right side of pause, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citynown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown ' State k` y i ,Code
,z.
Telephone Number
1
r•'
.B. Pumping Record C
C 467
1, Date of Pumping 2. Quantity Pumped: —�
Date p Gallons a
3. Type-of system: ❑ Cesspool(s) al6eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Pllter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of Syst m:
C(1k
UkA Q—
I
6. System Pumped By:
Nell.Bateson • F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ore contents-were disposed:
Lowell waste Water
LNfOA
SignAtute I Haule Date
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