HomeMy WebLinkAboutSeptic Pumping Slip - 120 LIBERTY STREET 9/7/2017 .5
RECEIVED
Commonwealth of Massachusetts
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System Pumping,. record t'Vj0EF 1MEl``AT
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CEP has provided this form for use=by local Boards of Health. Over farms 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.
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A. Facility. lnformlation
1. System Location Righ�qnt of house Left 1 Right'rear of house, Left/right side of house, Left/
Right side of buil i�eft/ tonta building, Left!Ri ht rear cif building, Under deck
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Address tc)-C)
Citylrown State - v Zip Code
2. System Owner:
k
Name•
Address(if different from location)
City/Town ' State ' 1� s�SCode
' F
Telephone Number
Pumping Record
9. Date of Pumping bate 2. Quantity Pumped:
Gallons
3, Type-of system: Cesspools) eptic Tank ® Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Ye, o If yes,was it cleaned? ® Yes No,
• 6. Condition of System:
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
?. Locatio contents were disposed:
.L S: Lowell Waste Water
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Sign a 9t Hhule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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