HomeMy WebLinkAboutSeptic Pumping Slip - 155 CHRISTIAN WAY 4/24/2018 Commonwealth of Massachusetts
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oSyitem Pumping-Record
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Form 4 P 2 4 Z018
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DEP has provided this form for use=by local Boards of Health. Other formilmaek'ugeda'btit 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 Pumping Record must be submitted to
the local Board of Health or other approving authority.
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1. System Location: Loft fight i�r nt pf hou e, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le tght front of building, Left/Right rear of building, Under deck
• Address C ,��`��'-- �"�(,�.�,,,,`t ". G"'�„`�„-�..• �� �"� � `�`-'�'J�..1-c5,
City/Town Mate Zip Code
2. system owner: i, _� i a •. .
Address(if different from location)
City/rown Stat �` ,. / 7�Cep Code ,
F "telephone Number
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.B. Pumping Record `}
1. Cate of Pumping pate 2. " antityPumped: Gallons
3. Type-of system: ❑ Cesspool($) Septic Tank El Tight Tank i
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? ® Yes ❑ No,
' S. Condition of System: ,-
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle t'lcense Number
Bateson Enterprises Inc'
Company
7. Lo ' n h contents,were disposed:
C L S: Lowell Waste Water
sign a HiuleiU pate
Wbrmkdocd 08/03 System Pumping Record• 'age 1 of 1