HomeMy WebLinkAboutSeptic Pumping Slip - 80 PHEASANT BROOK ROAD 11/21/2017 IVD
Commonwealth of Massachusetts REC E E
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HEALTH DEPARWEITF
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DEP has provided this form for use-by local Boards of Health. Other 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.
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A. Facfl ty Inform' atlon
1. System Location: Left/Right front of Mouse, Left ` ht rearoli , Left/right side of house, Left
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck t
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Address
City[rown state Zip Code
2. System Owner,
Name'
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Address(if different from location)
City/Town ' state ZiP.Cude
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Telephone Number ,
. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Efate Gallons ,.�"�
3. Type.of system: ® Cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o if yes, was it cleaned? ❑ Yes ® No,
b. Condition of stem:
C-
B. System Pumped By:
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location. ilie a contents-
were disposed:
/G.L S'- rr Lowell Waste Water
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Signk4e Higuie Date 1
t5form4.doc•06/03 system Pumping Record Page 1 of 1