HomeMy WebLinkAboutSeptic Pumping Slip - 307 REA STREET 6/13/2017 Commonwealth of Massachusetts
C4/Town of . a
S stem Pumping.Record
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DEP has provided this form for use-by focal Boards of Health. Other forma maybe 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 t,0
the local Board of Health or other approving authority.
A. Facility/ Informs atioin
1. System Location: Left ig 21,iggarcli
ou , Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Le rant of building, Left/Right rear of building, Under deck
• Address C) •
City(Town State Zip Code
2. System Owner:
Mame
Address(if different from location)
cityrrown State 7r' C�dp_
P Telephone Number
,i
• . Pumping Rpcord }
1. Date of PumpingDere 2. Quantity Pumped: Gallons s^
3. Typew system: ❑ Cesspool(s) c Tank El Tight Tank l
❑ Other(describe): '�
4. Effluent Tee Filter present's El ❑Yep ll_o if yes, was it cleaned? ❑ Yes ® No,
r
5. Condition of System•
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number )
Bateson Enterprises Inc-
Company
ncCompany
7. Lo tiertw e h contents were disposed:
C L S. Lowell Waste Water
i
2-
_ejynku a 9t Haule Date
Sform4.doc-06/03 System Pumping Record•Page 1 of 1
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