HomeMy WebLinkAboutSeptic Pumping Slip - 79 LACY STREET 7/23/2018 RECEIVED
Commonwealth of Massachusetts
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®EP has provided this form for use-by local Boards of Health. Other forms maybe used,but the
Information-must be substantially the tame as that provided hare. 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 t
the local Board of Health or other approving authority.
A. Fact0ty, ! i
1, System Location: Left/flight front of Hous a Righear o haus , Left/right side of house, Left I
Right side of building, Left/Right front of bul ding, Left/ "g rear if building, Under deck
Address
City/Town State Zip Code
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2. System Owner:
' 1
Name”
Address(if different from location)
CiWown StateCi,� C J } 'Code
Telephone Number +' 7
.B. Pumping R-picord
1. Date of Pumping Date 2. Quintity Pumped: Gallons r
3. Type-of system: ❑ Cesspool(s) +eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee 'Filter present? ❑ Yes q If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition of System- G��S
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6: .system Pumped By: t
Nell.Bateson F5821 1
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lote contente,were disposed:
Lowell Waste Water
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Sign a Fihul Gate
t6f6rm4,doo-06103 .System Pumping Record•Page 1 of 1