HomeMy WebLinkAboutSeptic Pumping Slip - 29 COLONIAL AVENUE 5/15/2017 wCommonwealth of Massachusetts
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City/Town 4
System lin .Record
Fqrm 4 IAEALTij[)rpARTMENT
DEP has provided this form`for use-by local Boards of Health. Other forms may be*used,but the
information-must be substantially the tame as that provided Pere. Before usin .thi 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. Facill.ty. Information
I. System Location: Left/Fight front of Douse, Left/Right rear of house, Left/ t ride of houW Left/
Right side of building, Left/Right fr6nt of building, Left/Right rear cif building, U dere (
Address
CitylTown State Zip Code
2. System Owner: Q ,,
Name'
Address(if different from location)
ity/Town Mate Zip Code
Telephone dumber
. r .
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-- 1
ion ., __ C
1. Date of Pumping rate . Quantity Pumped:
Gallons
3. Type-of system: esspool(s) eptic'Tank Fight Tank
Other(describe):
4.. Effluent Tee Filter present? Yes aft If yes,was it cleaned? El Yes No,
5. Condition of System:
6.• System Pumped By.,
Nell.Mason F5321
Mame Vehicle License Plumber
Bateson rter rises Inc'
Company
7. Location where contents-were disposed:
SS; Lowell Waste Water
Sign a H!3uie sate
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