HomeMy WebLinkAboutSeptic Pumping Slip - 64 SUGARCANE LANE 11/28/2017 Commonwealth of Massachusetts t ,
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SYsterm Pumping-Record 71
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DEP has provided this form far use#by local Boards of Health. Other forma 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 t®
the local Board of Health or other approving authority.
A. Facility. Information. _
1. System Location: Leftij1 ro ouse,�Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
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Citylrown State Zip Cotte
2. System Owner: '
Name'
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Address(if different from location)
CitylTown ' Stag ;
( 7-71
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F Telephone Number
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. Pumping record �
1. Date of Pumping gate 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) ® eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No,
5. Condibun of System: �J/(
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo id" M contents-were disposed:
CLS Lowell Waste Water
Signitu a qt Hauie Cate
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