HomeMy WebLinkAbout- Septic Pumping Slip - 169 LACY STREET 5/1/2019 t�
Commonwealth of Massachusetts
Cltiy/Town
System Pumping Record
W4
T '
uu IIIII� d
Form, V
DEP
has'provided this Iforim for use; y local Heal . Other forms maybe"Used, but the
info. M must be substintially the tame,as,that, provided here. Before using.this fog,6heck with your
to l Board , ffi to determine th, e for use. Thesubmitted
the local" Board of Health or others approving authority.,
A,. Facill ty Inforrhation
,w
1. System Location: RI �r house, Left *g sip house, Left
Right si � f bull, �" deft Rig �I � building,,
Address
Cityfrown state Zip Cody
System, we
Address(if differentfrom to
Co nowStater,,
Telepbone Number
I ecord ------
- .
Pump"ing
. Date of Purnping Date 2. W iinfity,Pumped: hone ----------
Type-ofrig k
0 Other(describe),
Filter4. Effluent Tee nth Ye,s R, 0 If yes, was it cleaned? Yes No
5. Condition of Systeml.
System Pumped BIr
Neff Batethri F5821
Name Vehicle LIcense Number
Bates h trees Ins*
Company
Lowell Waste Water
Sign t, a Hbul Dam
5 06103 System Vamping Record, Page i of 1
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