HomeMy WebLinkAbout- Septic Pumping Slip - 33 BEAVER BROOK ROAD 10/31/2018 Commonwealthf Massachusettsr Ei G rc
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®EP has provided this farm for useaby local Boards of Health. Other farms many be used,but the
information-must be substantially the same as that provided here. Before using.this farm,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 Informiation
1. System Location; Loft/Right front of house ig�h# ,ar f ho su Left/right side of house, Left/
Flight side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cityfrown state Zip code
2. System Owner:
Name'
Address(if different from location)
Cityfrown State 2` Code
Telephone Number
Pumping Record
r
1. ®ate of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) eptic Tank ❑ Tight Tank
❑ tither(describe):
4. Effluent Tee Filter present? ❑ Yes 01<0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S)rstem:�
6. System Plumped By:
Nell.Satesan F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. La ra contents-were disposed;
Lowell Waste Water
sign a Maul t7ate
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