HomeMy WebLinkAbout- Septic Pumping Slip - 218 LACY STREET 8/28/2018 Commonwealth of Masu
City/Town of . AUG 2 [12018
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DEP has provided this fora for use-by local Boards cf Health. Other forms maybe*used,but the
Information,roust be substantially the tame as that provided here. Before using.this fora,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. 11 Information ,
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
A dress
r An
cayfrown State Zip Code
2. System Owner:
Y(00 ' .
Dame"
Address of different from location)
City/Town ' State- Zip Code
6*-,,,,1-`0� - 43 4
telephone Plumber 1
• til 1
P
1. Date of Pumping > _ -- 2. Quantity pumped: 01 :n
Bate Gallons
3. Type-of systerW. ❑ Cesspool(s) ®'Septic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yets No if yes, was it cleaned? Yes ❑ No,
5. Condition ofystetn:
MOL(__
6. System Pumped By:
Bell.Meson - F6821
Flame Vehicle License number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
GLSrQ Lowell Waste Water
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t6fomn4.doo-06/03 System Pumping Record a page 1 of 1.