HomeMy WebLinkAbout- Septic Pumping Slip - 120 HAY MEADOW ROAD 9/24/2018 Commonwealth of Massachusefts
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cSyMem Pumping,RecordEi
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DEP has provided this forf6 for use-by local Boards of Health. Other form may be bsed, 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 Health or other approving authority.
•
A. Fact0ty. InforMation
I. system Location: Left I Eight front of boos Loft igh ea��ofl--
; ,,,eftI right side of house, Left/Right side of building, Left/Right front of bur ding, Left/ f building, Under deck
Address
City/Town state Zip code
2. System Owner:
Name"
Address(if different from location)
cityrrown ' State Zi co
5
Telephone Number �
R
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® Pumping Rpcord
1. Date of Pumping crate 2. Qu6ntity Pumped:
f. Gallons ����"
3. Type-of system: El Cesspool(s) eptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yet No If yes,was it cleaned? ® Yes ® No,
' . Condition of System:
4t
6: .system Pumped By:
Neil.Bateson - F5821
Name. Vehicle License Number
Bateson Ehterprises Ina j
Company "
i
7. Loco' contents•were disposed:
MILAJD Lowell Waste Water
d
SignAtu a PbuleruDate
t5form4.docd 06/03 System Pumping Record o Page 1 of 1