HomeMy WebLinkAboutSeptic Pumping Slip - 33 SULLIVAN STREET 4/24/2018 Commonwealth f Massachusetts /I
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DEP has provided this four for use-by local Boards of Health. Other forms may bused,but the
information,must be substantially the tame as that.provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FacMty Informiation .
1. System Locatio : L Righ on_ of , Left I Right rear of house, Left/right side of house, Left
Right side of bull ing, Left/Right front of building, Left/Right rear df building, Under deck
Address ...
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Cdylrown state Zip Code
2'. System Owner:
Address#f different from location)
CitylTown ' State , ip Cade
P Telephone Plumber
r
1. Date of Pumping 2. Quantity Pumped:
Cate Gallons
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3. Type-of system: El Cesspool(s) 0--teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y" a If yes, was it Cleaned? Yes No,
6. Condifio of stent: �� )
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6: System Pumped 6y:
Neil.Satesion " F6621
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Lo ti ere contentsrwere disposed:
L S Lowell Waste Water
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SignAtWufs Fiaule Cate
tftrm4.doo•06/03 System Pumping Record page 1 of 1