HomeMy WebLinkAbout- Septic Pumping Slip - 371 STEVENS STREET 5/15/2019 i
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Commonweialth of Massachusetts
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System
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Form 4
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DEP has provided this form for us&by local Boards ofHealth. Other formt;
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used,but the J
lnfbrmaffon, st be subst6nflallVusing. k with
loc,61 Board of Health 6 determine the fo ' they use.The Pystem Purniping Record must be submed to
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A. Facility InforMation
1'. System Location: Left/Right front of,house, Left/91' "rearofhou., Left./right,side of house, Left,/
Right side,of building, Left ,fr6rit of buildirig, t ., building,,
ress
cKyrrown slate Zip Cody
2". System Own
Name*
Address Of differentT m location)
Cityn,own scat Code
m
Telephony Number
B. Pumping Record
. Date olf PumpingDate 2. Q ti �Pumped: Gallons
3. y _: l0--Se�lc'Tank 0 Tight
E] Other
(describe):
4
No., EffluentIter Present?
-, - BJ,+f6"' if -.�TM .: - -. -m Yes .....
5. Condifion
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System Pumped By.-
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Name Vehicle,U use Number
Bateson i Inc-
Company,
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disposed.--
Lowell Waste Water
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slignit,11,4
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fDate
,, ,h08/03 System Pumping Record Page I of 1