HomeMy WebLinkAboutSeptic Pumping Slip - 350 BERRY STREET 10/31/2016 Commonwealth of Massachusetts
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City/Town of RECEIVED
System Pumping.Record NOY lb ZU16
Form 4
�• TON coo--NOK i.-a Kac)OVE
HEAL, H DEPM �c'ML N'F
DEP has provided this form for use=by local Boards of Health. Other forms may' a 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 Locati . Le i</ Iggot t of Left/Right rear of house, Left/right side of house, Left/
Right side of bur mg, Left front of buildlrig, Left/Right rear of building, Under deck
Address
cityrrown State Zip Code
2. System owner.
Name'
Address(if different from location)
citytrown State , Zip Code
a Telephone Number
i
.B. Pumping record
03
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y� "
3. Type-of system. ❑ Cesspool(s) 01- eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
I
' 5. Condition of System.
� C. t .�
6: System Pumped By.
Nell.Meson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca'ar> re contents-were disposed:
Lowell Waste Water
-gignAtife I Haule Date
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