HomeMy WebLinkAbout- Septic Pumping Slip - 230 FOREST STREET 5/1/2019 64
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Commonwealth
Coty[Town of' Massachuseff,s
of'
V
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i
�N
Record
a
systeM
Pumptng
Form 4
DEP has provided this form for usep by,local Boards -Health. Other for maybe bsed,,but
informs ly the tame,as that provided here. Before using.his foun,check with your
local!Board of Health to determines the forrh they use.TbeSystem PurnpingRecord mus,t be submitted
the local Board'of Health �or other approving authority,
A,, Facility Inform, afloon
'. front " �rear , r side Left I
Right side of building, Left Right,fron,o 'uildirig, Left/Right rear df buildm" g, Under deck
Address
offyfrown State Zip Cody
2,. System Owner.,
Name
Address i'differentfrom to fl
City/Town Slatj1( �ide
Telephone Number
.B. Pumping Record
1. n,ty Pumped:
Data Gallon
. l( .. Tank Tightk
Other(describa),-.
4. Effluent Tee Filter,present? Yes If Yes, wasift cleaned? El- Yes El, No
5. ffiors of System:
y=
Nell
Name Vehicle License Number
Company
where7. Location
Lowell _r
Sign e Hhul Date
t5form;4.d000 06/03 System PumpingRecord