HomeMy WebLinkAbout- Septic Pumping Slip - 337 PLEASANT STREET 5/1/2019 CommonweialthUty/Town
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Form 4
DEP has rvi
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i r n-must be subst6nffallythe tame as that providedhere. Before using.this form.,check,with your,
l .1: Board ofHealthin M they s TheSysltem PumpingRecord must be submitted
the local Board of Health or other approving authority.
,A,. Facility InforMation
System : front of house, fight rear ofhousp, Left./rI side of house, Left
Right side of it rear df building, Under deck
Address 1�
Ofty/Town State Zip Code
'. System Owner:
Addressi location)
City/Town Stal Zip Code
Telephone Number
1
R Pumping
Record
L 2,., Qu6nfit
1. Date of Pumping ate y Pumped: Gallons, ............
. Tight
OtherE] (describe):
t
. Effluent Tee Filter present? 0 Yes l � yes,,was it cleanedo? Yes No
1
5.
Condition
SystemLat � -
6.
Nell.
VehicleNarne Number
Batt
es
Company
T Location re ci were is
LowellWaste Water
40
819*4 H,13ul low
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