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HomeMy WebLinkAboutSeptic Pumping Slip - 45 WHITE BIRCH LANE 10/29/2016 Commonwealth of Massachusetts l iCity/Town of I D ?016 a System Pumping.Record Form 4 HUkLT H U,PA RT ME"NT 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. Information 1. System Location: Left/Right front of hous , lgh f hou Left/right side of house, Left/ o Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name' Address(if different from location) City/Town ' Stag qr_ ip.,Code t Telephone Number % i .B. Pumping Jkacord 9. Date of Pumping Date 2. Quantity Pumped: Gallons k 3. Type-of system: © Cesspool(s) peptic Tank ❑ Tight Tank i. ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: 6. System Pumped By: Nei[Bates-on F5821 Name Vehicle License Number Bateson Enterprises Ina Company 7. Locatio wrhere contents-were disposed: i /61S.V Lowell Waste Water I .. Sign a I HguleV Date t5form4.doc-08/03 System Pumping Record•Page 1 of 1