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HomeMy WebLinkAboutSeptic Pumping Slip - 850 JOHNSON STREET 11/16/2016 Commonwealth of Massachuse##s RECEIVED _ City/Town of . System Pumping.Record Form 4 TOWN OF NU I H NU�a HEALTH DEPARTMENT DEP has provided this form'for use:by local Boards of Health. Other forms maybe*used, but the information-must be substantially the same as that provided here. Before using.this form, ' heck 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 house, Le IC1lt rear of k­ Left,/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address r� City/Town State Zip Code 2; System©weer. � • Name' Address(if different from location) Cityfrown State Zip Code ; Telephone Number ss t .B. Pumping Kecord 1. Date of Pumping sate e_ Quantity Pumped: �.. Gallons ,. • A 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? r_1 Yes ❑ No, 5. Condition of System: 1 , 6: System Pumped By: Nell.Bates-on 1=5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Locatio ire contents were disposed: z. G L S'. Lowell Waste Water 4Sign *eHaule Date t5f6rrn4.doc•06/03 System Pumping Record•Page 1 of 1