HomeMy WebLinkAboutSeptic Pumping Slip - 970 JOHNSON STREET 6/14/2017 Commonwealth of Massachusetts
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System Pumping-Record
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MP has provided this form for use>by local Boards ofHealth. Cather forms maybe'used,but the
information'must be substantially the same as that provided here. Before using.this 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. Facility. Informlation
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
. Cityr'1'own State � Zip Cgde
Telephone Number
a
.13. Pumping Record
62
1. Cate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
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❑ tither(describe):
I
4. Effluent Tee Filter present? ® Yes a If yes, was it cleaned? ® Yes ❑ No,
' 5. Condition f stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7.
cation 7e contents were disposed:
`� f
S. Lowell Waste Water
Sign a qf HilulwU Date
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