HomeMy WebLinkAbout- Septic Pumping Slip - 144 CRICKET LANE 9/24/2018 Commonwelafth ®f Massachusetts
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DEP has provided this form for use:by local Boards 6f Health. Other forms maybe*used,but the
information,must be substantially the tame 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 t®
the local Board of Health or other approving authority.
A. Facility Information ,
1. System Location a ig s eft/Right rear of house, Left/right side of house, Left
Right side of bui� , Left I Ri igt front of building, Left I Ri ht rear®f bu'rldin . under deck
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Address
(".Ity/rpwfl State Zip Code
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2. System Owner: �
\6
garner"
Address(if different from location)
ClWown ' State• Zip C
Telephone Number
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.B. Pqmping Record
1. Gate of Pumping date 2. Quantity pumped: Lallans
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3. Type-of system`. ® Cesspool(s) eptic Tank El Tight Tank
Other(describe).
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? El Yes El No,
6. Condition of System:
6. System Pumped 6y.
Nell.Batesiog F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w re contents-were disposed:
M Lowell Wash Water
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Sign a Raul Cate
t5form4.doc•06/03 System Pumping Record p 'age 1 of 1