HomeMy WebLinkAboutSeptic Pumping Slip - 162 GRAY STREET 5/22/2018 Commonwealth ® Massachusetts
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System Pumping-Record i ion
Form 4 HEAMi Dr;;
REP ha'provided this form`for use-by local Boards 6f,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 forrh they use.The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility Information,
1. y tear Location: Lc Ri t rtt of house eft//Dight rear of house, Left/right side of house, Left t
Right side of building, Left I Right fron o uildirig, Left I Flight rear of building, Under deck
Address
<: k— .
City/Town state Zip Code
2. System towner:
' Name'
Address(if different from location)
Citylrown � '. State
Telephone Number ?'
Y'
B. PumplingiRpcord
1. Gate of Pumpingcrate 2. Quantity Pumped: Gallons��`
3. Type-of system: El Cesspool(s) � eptic Tank El Tight Tank y
El Other(describe):
4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? El Yes El No,
5. Condition of Syst
6; System Pumped Ey:
Nell.6ateson - P5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7, Locatio ti re contentsrwere disposed:
Lowell Waste Water
' F
Sign a HilulwuCate
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