HomeMy WebLinkAbout- Septic Pumping Slip - 33 SULLIVAN STREET 5/1/2019 Commonweial'th of Massachusefts
Cilty/Town of
System Pumping Record
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DEP has provided thi's form for use;,by local Boards offlealth. Other forms may,bebsed, b"ut the
information,must, be substinflaIl'y the same as that provided here. Before using.this form,,check with your
lockil Board of Health to determine the for M' they use.The$ystern Purnping Record must be submitted,to
the local Board'of Health or other approving authority.
A. Facility InforMation
f Cron t:o)Tf:hn o
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11 System LocaHom, gh front of ho Left Right rear of houso, Left ri"ght side of house Left,/
ht t
c3 nt of b, rear df build" g, Under d
Right side of Wig' go, Leflft I R-119 ro of buildifig, L�eft/'Right M eck
Address sl� I qc:� (7
c7ofrowe State Zip Code
2. System Owner,.,
Narneo
Address(if different,from location)
CiWTOWO Zip Code
...............
Telephone Number
.B. Pumping Record,
1., Date of Pumping Date Quiinti Pu ed,, GaflonS
I Type-of systern.- Cesspool -156pfi ight Tank
Ej Other(describe):
4. Effluent Tee Filter present? El Y If yes, was it cleaned? 0- Yes El No
fill
5. Condifion of Sy rtel
6. System Pumped By.--
Nell. g F5821
Narne Vehicle License Number
Bateson rlses lnc,
Company
7. Lo r content&were disposed.p,
8. 4
Lowell Waste:Water
ti
.......... . .......
star, HUI Date
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