HomeMy WebLinkAboutSeptic Pumping Slip - 76 CARLTON LANE 5/22/2018 RECEIVED
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c Commonwealth of Massachusetts
MAY 2 2 7018
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DEP has provided this form*for uswby local wards of Health. Other farms may used,but the
information-must be substantially the same as that provided here. Before using.this farm,check with your
local ward of Health to determine the for(h they use.The System pumping Record must be submitted
the local ward of Health or other approving authority.
A. Factoty, Inform' ationr
1. System Location: Left/Right front of douse, Left]Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State zip(;ode
2. System Owner:
Dame'
Address(if different from location)
City/Town ' Staters �t�, Zip
F
'telephone Number
i
B. Pumping Rpcord
A
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1. Gate of Pumping pate 2. Quantity}'umped: Gallons
f
3. Type-of system: d Cesspool(s) ptiC Tank El Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes f If yes, was it Cleaned? Yes ❑ Na
5. Condition of System: 1
6. System Pumped By.
Nell.Bateson F5821
Name vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo bh W here contents-were disposed:
S: Lowell Waste Water
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F
Sign Fi�ule Cate
t5form4.doc-46/43 System Pumping Record gage 1 of 1