HomeMy WebLinkAboutSeptic Pumping Slip - 380 BOXFORD STREET 4/24/2018 Commonwealth of Massachusetts
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City/Town of � � � �� A °?
SyWm Pumpling. ret cOmM ��:r �u .
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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 tame as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Dumping Record must be submitted>c)
the local Board of Health or other approving authority.
A. FacHRY, Information
1. System Location: Left/Dight front of HousLe tog t yea of house,�,eft./right side of house, Left/
Right side•f building, Left/Right front•f bul diri9, Left/ i,g rear if Yuilding, Under deck
• Address
City/rown State Zip Code
2. System Owner.
• Name'
Address(if different from location)
City/"rown Stat � � .�.�.., ip
ZCode
• F 'telephone Number4�
i
B.
Pumping li c r �
1. Mate of Dumping late 2. «u6ntity Pumped: Gallons
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3. Type-of system: ® Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes o If yes, was cleaned? ® Yes Na
5. Condition of System:
6: System Dumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
%L Lowell Waste Water
Sign a Hhule Date
t formCdoo•06/03 System Pumping Record•Page 1 of 1