HomeMy WebLinkAboutSeptic Pumping Slip - 208 SUMMER STREET 1/17/2017 Commonwealth of Massachusetts
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City/Town of
i -Record JAN i
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DEP has provided this form far use-by local Boards of Health. Other forms may be'used, but the
information,must be substantially the itame as that provided hare. Before using.this farm,check with your
local ward of Health to determine the forth they use.The System Pumping Record must be submitted t,
the local Board of Health or other approving authority.
A. Factfl.ty. Infor tion
I. System Location: Left/Right front of house, Left/Right rear of house, rig side of� eft
Right side of building, Left/Right front of building, Left/Right rear of building, Un er �p
Address 55,u� �-
J
City/Town Mata Zip Gado
2. System Owner
Puma'
Address(if different from location)
GityfTewn '
State-
Telephone
tate Telephone Plumber
,i
Jff
m—Pumping
?. hate of Pumping Cate 2. Quantic Pumped G� t
Gallons
3. T e�of s stem`:
yp y 0 cesspool(s) eptic Tank El Tight Tank
El t
Other(describe):
.t
4. Effluent Tee Filter present? [] Yep Nlo If yes, was it cleaned? ® Yes ® No,
' S. Condition of System:
LAJ
�
6. System Pumped By:
Nell.Bat ern ' F5321
Name Vehicle License Plumber
Sateon 6�ses lnc
company
7. Lo 'on. re contentswrere disposed:
_L S. Lowell Waste Water
�Ign a H ule Date
MormCdoc•06103 System Pumping Record®Fuge 9 of 1
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