HomeMy WebLinkAboutSeptic Pumping Slip - 31 JAY ROAD 3/12/2018 Commonwealth of Massachusefts "ED
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Sy,4tem .
Pumping.Record
Form 4DE
®EP has provided this form'for use-by local Boards 'of Health. Other forms may be'used,but the
information-must be substantially the tame as that provided hare. 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.
1. System Location: Loft fight front of House.;"Lei!Right rear of house, Left/right side of house, Left
Right side of building, Le Right front of building, Left/Right rear df building, Under d�rrk
Address
City/Town state Zip code
2. System Owner
y`�
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Address(if different from location)
City/Town state Zip Cade
"telephone Plumber
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9", C")
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1. Mate of PumpingDate 2. Quantity Pumped:
Gallons
3. Type-of system: El Cesspools) eptle Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® No If yes, was it cleaned? es ® No,
6. Condition of.System:
I
6: System Pumped By:
Nell Bates7on ' F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
�LLowell Waste Water
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Y
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sign a Hlul Cate
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