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HomeMy WebLinkAboutSeptic Pumping Slip - 381 SUMMER STREET 12/4/2017 C©MMonwealth of Massachusetts 4 ClWTown of . System Pumping.Record Form 4 I EP has provided this form for use-by local Boards of Health. ether 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. A. Facility Information 1. System Location: Left/Right front bf house, Left/Right rear of house, Left si , Left 1 tp Right side of building, Left 1 Right front of buildirig, Left 1 Right rear of building, Under deck Address c �-- — Cityrrown state Zip Code 2. System Owner. Name' Address(if different from location) CityCrown State- Telephone Number 3 1 .B. Pumping Record 1. ®ate of Pumping 2. Quantity Pumped: Cate Gallons I Type-of system: ® Cesspool(s) ptic Tank ® Tight Tank ; ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes if yes, was it cleaned? ❑ Yes ❑ No, v. Condition of Syste c 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Locatio w contents-were disposed: R C L Lowell Waste Water ��--� '7 F Sign a Hhul Date t5fcrm4.doc•08103 System humping Retard•Page'i of 7