HomeMy WebLinkAboutSeptic Pumping Slip - 78 TANGLEWOOD LANE 1/9/2018 Commonwealth of Massachusetts
_ City/Town of .
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Sy.4tem -umpip§.Record
Form 4 'M)N UNQ ffl
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DEP has provided this form for use-by local Boards of Health. Other forms 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 to
the local Board of Health or other approving authority.
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A. Facility. Information
1. System Location: Left/ nt of 17ouse, Left I Right rear of house, Left-/right side of house, Left 1
Right side of building, Left/Right fron of building, Left/Right rear cif building, Under deck
Address - ...
City/rown State Zip Code
2. System Owner:
Name`
Address(if different from location)
Citylrawn .' State . Zip Cade ;
'telephone Number {`
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. » Punnpiing Ripcord g
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. "Type-of system: Cesspool(s) p6f a
n ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? Yes o .~ If yes, was it cleaned? F Yes ® No,
5. Condition of System ,
6. System Pumped By:
Neil.Bate son - F5821
Name Vehicle license Number
Bateson Enterprises Inc,
Company
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7. Locationjw a conte�atswere disposed:
,.L SLowell Waste Water
CjYTO
Sign a 9f HauleV Crate
0orm4.doc•06/03 System Pumping Record a Page 1 of 1
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