HomeMy WebLinkAboutSeptic Pumping Slip - 12 FARNUM STREET 12/11/2017 Commonwealth of Massachusetts
City Town of .
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System Pumping.Record
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DEP has provided this form foase:by local Boards of Health.Other form's 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 farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. lnforMation
1. System Location; Left/Right front of house, Left/Right rear of houser�ght de o�house, eft1
Right side of building, Left 1 Right front of buildirig, Left/Right rear of buiidmg, Under e
Address
Citylrown state - Zip Code
2. System Owner.
fi V�V\.
Noma'
Address(if different from location)
Cityfrawn Stater7f L Zig Code
Telephone Number
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.B. Pumping Record
1. Date of Pumpingdate ( 2. Quantity Pumped: Daltons
3. Type-of system: ® Cesspool(s) ❑ Septic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Ye
s No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste �
up "
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enter
prises Inc
Company
7. Lccabo here contents-were disposed:
4signe
kMaule
Lowell Waste Water
Date
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