HomeMy WebLinkAbout- Septic Pumping Slip - 90 WINTERGREEN DRIVE 5/15/2019 Commonwealth of Massachusetts
C KY/Town of
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System
Form 4Pumpi
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M 111 ecord
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DEP has,provided for useoby local Boards ! their form may'be'Used, but the
information,must be substintiagy the tame s that providedhere. Before using.this fog,6heck with your
t l r Health determine the forte they . h Pumping e r � l ire
the local Board'of Board' Health r other approving authority,
A. Facility Inf6rMation
1
. System L Left Right front house, right side ofhouse, Left,
side il 1n , Left Right fr6nt of1buildifig, fight rear df building, Under deck
Address
CRYfrown state Zip Cody
e
Owner,System
Name*
Address(if different,from location,)
Citynown stete.16
Telephonebar
1.B. Pumping k-ecord
Date of Pumping
3. Type-of system: E) l(s) [3--8'eptj*c T ank i n
Other(describe):
W _
4. Effluent Tee
Filter r0"�Y�esE] If i
5. Condition of Sy.
ift
6.
w
System
ll, 7
Name 'Vehicle License Number
Bateson ! r s Ine
Company
contents. l
Lowell Waste Water
w
Sign a Hhul Date
.doah 08/03, System Pumpingr' e Page 1, of I