HomeMy WebLinkAboutSeptic Pumping Slip - 455 CHESTNUT STREET 4/24/2018 Commonwealth of Massachusetts
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System Pumping.Record MIR 2.� 1201
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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.
A. Facility information, � .
1. System Location: Left/Right front of Rause, a Right ear of hou eft/righ#side®f house, Left!
Right side of building, Left/Right front of buil :rig, Left/ ear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown State- � p de
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Telephone Number '
. Pumping.,Rpcord
9. Date of Dumping nate 2. Quantity Pumped: Gallons
3. Type•of system.' ❑ Cesspooi(s) pfic Tank ❑ Tight Tank
❑ Other(describe):
d•. Effluent Tee Filter present? ❑ Yep a if yes, was It cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
Neff Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
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7. Locati mwhere contents-were disposed:
^L S: Lowell Waste Water
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Sign l e Haule Date (J ( b
t5form4.dov 06/43 System Pumping Record•Page 1 of 1