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HomeMy WebLinkAboutSeptic Pumping Slip - 328 SUMMER STREET 11/16/2017 Commonwealth of Massachusetts Cjty/Town of System Pumping.Record Form 4 ON J\0 ©EP has provided this form for use-by local Boards of Health. 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. fi A. Facility. InforMation y 1. System Locabo Rig tort of hquse Left/Right rear of house, Left/right side of house, Left 0 Right side of but g, Left/RigFit fr©nt of buildiirig, Left/Right rear of building, Under deck Address C" . city/Town State Zip Cotte 2, System Owner: Name' 1 Address(if different from location) City/Town ' State- ip de Telephone Number 't Pumping Kecord 1. Date of Pumping gate 2• Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) ❑9ep nk ❑ Tight Tank ❑ Other(describe). 4. Effluent Tee Filter present? ® Yes ❑ 10If yes, was it cleaned? ❑ Yes ® Na 5. Condition of System 6. System Pumped By: l Nell.Bateson F5821 Name Vehicle license Number Bateson Enterprises Inc, Company 7. Location where contents were disposed: ^L Lowell Waste Water Sign a I-HilulevDate t5form4.doc•06/08 System Pumping Record•Page 1 of 1