HomeMy WebLinkAbout- Septic Pumping Slip - 1491 TURNPIKE STREET 6/4/2019 Commonwealth of Massachusefts RECEIVED
Goty/Town of
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Ad System Pumpino Record i.
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INI'NOM Or''NORTH AND(),VER
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i-EALTA DPW—[1"'VIENT
DEP has provided this forim fori useby local,Boardsofflealth. Other foirmt ma I y'be'used,, but this
informadon,must be:subst6nitially the tame as that provided here. Before,using.this form, ,check with your
local Board of Health to determine the for M* they use.,The$ystern Pumping Record must be submitted,tc)
thie local BoarV of Health,or other approving authority.
A. Facility Inform' afloon
S
00 �ystem Location: Left Right front of house, Left Right,rear of house, Left I<ght side ofhouse Left I
R U e ight si of building, Left Right fr6nt of buildIfig, Left, Might rear cif buildli r
Address
Cr state zip Code
2'. System Owner.
..........
Nama'
Address Of different from location)
Cityf row,a stad • do
'Telephone INumber
...................
B. Pumping Record,
C
..................
1. Date of Pumping Date 2. uuanflo umpe Gallons
3. Type-of system:.i Cesspool(s), 3,1�epfic Tank [I Tight Tank
Other(descriabe):
4. Effluent Tee Filter present? [j Yes 911. 'o If Yes,, w,as it cleaned? Yes No,
5. Condiflonof System:
6, Systern Pumped Byi
Nell.Batesion F5821
Name Vehicle 1:1cense Number
as rises Ehte!!prises line
Company
7. Loca contents-were disposed.
-Lowell Waste!Water
rib
Sign
Hlbul Da�te
t5fbrm4.doc*06,103 System Pumping Record page 1 of I