HomeMy WebLinkAbout- Septic Pumping Slip - 10 STILES STREET 8/28/2018 Commonwealth of Massachusetts
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Sy.4tem Pumping.Record
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Fora 4 raNN OF f\2P,r. H M\fl,"JOVE
DEP has provided this form for use-by local Boards of Health. Other forms maybe•used, but the
information-must be substantially the Larne 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 1
the loom Board of Health or ether approving authority.
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A. Facility InforMation {
1. System Location: Loft t front pf hou , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig��anf building, Left/Right rear of building, Under deck
. Address
City/Town State Zip Code
2. System Owner:
Name`
Address Of different from location)
Ci awn
• Stat r �ip e w
F Telephone Number
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Pumpling Rpcord
1. Date of Pumping Date 2.. Quantity Pumped: Gallons
3. Typ&of system: CJ Cess oel s
p ( ) rank El Tight Tank • '-
[] Other(describe):
4. Effluent Tee Fitter present? Yes 0-M-0— If yes, was it Cleaned? Yes No,
5. Condition of system: 1
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6: System Pumped By:
Neil,Bateson • F5321
Name Vehicle License Number
Bateson Enterprises Inc•
Company
7. Lo ti ere contents•were disposed:
C S Lowell Waste Water
Sign a i"Ibul Cate
0brm4.do 06/03 System pumping Record.page 1 of 1