HomeMy WebLinkAbout- Septic Pumping Slip - 34 LIBERTY STREET 10/31/2018 Commonwealth of Massachusetts
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City/Town of
U18
System Pumping Record (XJ 31
Form 4 TOVJN OF�,O(f H OWOVER
HEALTH DEFIARTMEKT
DEP 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 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
the local Board of Health or other approving authority.
A. Facility information
1. System Location: Left front of house Left/Right rear of house, Left/right side of house, Left I
4*1 *ig4 Right side of building, Left Right rOnt GioUildifig, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner
Name'
Address(if different from location)
CiwTown Stater Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumpingrate 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) 9--S6pfic Tank El Tight Tank
[3 Other(describe):
4. Effluent Tee Filter present?' [] Yes o If yes, was it cleaned? 0 Yes E] No
5. Condition of System:
6. System Pumped By.
Nell.Rat e6bv F5821
Name Vehicle License Number
Bate§on Enterprises Ina
Company
7. Location where contents-were disposed:
ML Lowell Waste Water
gilgonle 144hul ) Date
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