HomeMy WebLinkAboutSeptic Pumping Slip - 140 CHRISTIAN WAY 9/30/2016 Commonwealth of Massachusetts
City/Town of
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System Pumping, Record
Form 4 G r
DEP has provided this forrri for use-by local Boards of Health. Other form$,fmsy lye t o ,,bi i�tie
information must be substantially the same as that provided here. Before using,this fom,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/Right front of douse, Le rear of ho su'Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address � � �k��`� / "1 ...� �•�'vti.
Gity/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
city/Town Stat
1-7�\ y( r( y(}Zi eoe r ;
F _
Telephone Number ==3.
r
.B• Pumping R"mcord
1. Date of Pumping Date 2. Quantity Pumped: Gallons —'
3. Type-of system; ❑ Cesspool(s) 0--Sec ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System•
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati n herl contents-were disposed:
O LS: Lowell Waste Water
ALA
Signitufe, Haule Date
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