HomeMy WebLinkAboutSeptic Pumping Slip - 99 HAY MEADOW ROAD 11/28/2017 Commonwealth of Massachusetts1°4' *, wN
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City/Town of
System Pumping.Record
4
Form
DEP has provided this form for use-by local Boards of Health. Other forms maybe used,but the
informafton'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 t4
the local Board of Health or other approving authority.
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A. Facility Informlation
1. System Location: Left/Right froant of house, Leff/Right rear of house, Left./f f hau.s�, Left l
Right side of building, Left I Right front of building, Left 1 Right rear of building, Under deck
Address ^
City/Town State Zip Code
2. System Owner. .
Name'
Address(if different from location)
CitylTown State-
Code
t 19
Telephone Number
t ,
. Pumping Racord .
1. Date of Pumping nate 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? 0 Yes 040 If yes,was it cleaned? Yes ® No.
5. Condition of Sy tem:
f�,,
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio where contents were disposed:
CLS; Lowell Waste Water
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aigna Hanle Cate
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System Pum Record Page 1 of 1
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