HomeMy WebLinkAboutSeptic Pumping Slip - 76 EVERGREEN DRIVE 5/15/2017 Commonwe'alth of Massachusefts
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Pumping.
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DEP has provided this forms for use-by local Boards of Health. Other forms maybe•used, but the
information must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. Tire System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. In Ir ti l
4.
1. System Location: Left I Right front of house, Left Left/right side of house, Left I
a Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/T'own — State Zip Code
2. System Owner: _ >
Name'
Address(if different from location)
citylrown State - --. / de
ta Telephone Number.B. Pumping Rqcord
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°I. date of Pumping fate / 2. Quantity Pumped:
Gallons
. Type-of system: El Cesspool(s) eptic Tank El Fight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yep a If yes,was it cleaned? Yes No,
' S. Condition of first
6., System Pumped By:
Nell.Batesbn P5821
Name Vehicle License Number
Bateson Enterprises Inc
company
7. Lo here contents were disposed:
L S: Lowell Waste Water
17
Sign a Hauls Date
t form4.docm 06103 System Pumping Record®Mage 1 of 1