HomeMy WebLinkAboutSeptic Pumping Slip - 1510 SALEM STREET 12/28/2016 wealth of Massachusetts
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Form,Sy.4tem Pumpling.Record 16
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DEP has provided this form'for us&by local Boards of Health. Other forms may used,6�,`�$�te
Information'must be substantially the same as that provided here. Before using.this form.,check with your
local Board of Health to determine the forth they use. The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
Facility. Infor fi n
1. System Location: Left/Fight front of hour L Iglt rear f hour , Left/right side of house, Let:/
Right side of building, Left/Right front of bui In , Left/Pigh 'rear building, Under deck
Address
cityfrown State Zip Code
2. System Owner: , � (
�_c
Name'
Address(if different from location)
'rfyfTown ' State ry ip code
F
f C�
Telephone Plumber
'b
w Pumpong Rqcord
./
1. Bate of Pumping Date 2• Quantity Pumped:
Gallons
. Type-of system: El Cesspools) eptic Tank D Tight Tank
El Other(describe): --�
4. Effluent Tee Filter present?- Yep a o If yes, was it cleaned? E Yes 0 No,
' S. condition of System:
6. System Pumped By:
Neil.Bat on ' F6621
Name vehicle License Number
Satepon Ehiterprises Inc'
Company
7. Lo fian-) :ere" ntents were disposed: IF
_S. Lowell'Taste Water
Sign 'a Hijuie Date
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