HomeMy WebLinkAboutSeptic Pumping Slip - 506 BOSTON STREET 6/12/2017 Commonwealth of Massachusetts
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System Pumping-Record � �� ��
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DEP has provided this form for use-by local Boards 6Mealth. Other forms may be'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 InforM' afion
i
1. System Location: Left]Right front of Mouse, Left/Right rear of house, Left/right side of house, Leff
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'
t
r
Address(if different from location)
City/Town state&
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'telephone plumber +`a
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Pumping Record
1. Crate of PumpingDate 2. Qua 'ty Pumped:
Gallons ,.
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? e ® No If yes, was it cleaned? es ❑ No.
5. Conditio Ter r
" / (/(yam . Y'".
�.
6. System Pumped By: A/
Neil,Batesbn F6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locati f0kh" re contents�were disposed:
CLS, Lowell Waste Water
SignAqt Haule Cate
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