HomeMy WebLinkAboutSeptic Pumping Slip - 220 CANDLESTICK ROAD 6/1/2017 Commonwe'alth of Massachusefts
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Sy.4tem Pumping.Record
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DEP has'provided this form for use�by local Boards of Health. Other fo maybe bsed,but the
information-must be substantially the same as that provided here. Before using.this form,c'heck with your
local Board 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.
A. Facility Information
1. System Locatio a igh ont of 1louse, Left/Right rear of house, Left./right side of house, Left/
Right side of building, Left/Right front of buildidg, Left/Right rear df building, lender deck
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Address
citylrown State Zip Code
2. System Owner:
Name*
Address(if different from location)
City/Town ' state � —.-ZIP
i co e
Telephone Number.B. Pumping Rpcord
-17
1. bate of Pumping Yale 2. Quantity Pumped:
Gallons
. Type-of system. El Gesspool(s) c eptic Tank El Tight Tante
El Other(describe):
4. Effluent Tee Filter present? El Yep o If yes, was it cleaned? E Yes 0 No,
. Condition of Syste
6: system Pumped By:
Nell.Bateson P5321
Name Vehicle License Number
_Bateson Enterpri��
Company
7. Lo tn, here contents were disposed:
Lowell Waste Water
Sign a Haule date
t5fomm4.doc-06!03 system Pumping Record Page 9 of 9