HomeMy WebLinkAboutSeptic Pumping Slip - 49 EQUESTRIAN DRIVE 1/17/2017 Commonwealth of assachuse
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Form iiEALM DEPARTMENT
®EP has provided this form far 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 farm,check with your
local ward of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
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1. System Location; Left/Right front of douse, Left/Right rear of house, Left/right side pf house, Loft/
5 Right side of building, Leff/Right front of building, Left/Right rear of building, Under deck
Address
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City[rown Mata zip Cade
2. System Owners
Name }
1
Address(if different from location) - �
City/Town - state Zip Code
Telephone Number
i
.B. Pumping Rpcord
t. Date of Pumping Data 2. Quantity Pumped:
Collette _�_`:
. Type,of system. Cesspool(s) eptic Tank Tight Tank t
El Other(describe):
4. Effluent Tee Filter present? El Yep o If yes, was it cleaned? E Yes No,
6. Condition of System-
6., System Pumped By:
Nell.Bateson F5821
Name Vehicle Liaanse Number
Bateson EhteTrises Inc,
Company j
7. Location where contents were disposed.
4819nW66
Lowell Waste'V'W'ater
Flaula Cate f
I
tforrn4.docm 06103 system Pumping Record®Page 1 of 1