HomeMy WebLinkAbout- Septic Pumping Slip - 1650 TURNPIKE STREET 6/4/2019 'ED
Commonwealth of Massachusefts
FtV,:,O0EIV
V "T
ry
Uty/Town of
System Pumping Record
Form 4
DEP has provided this fbrm for usep by
local BoardsHealth. Other formic mad 'Used,but the
l
information, i a that providedherecheck
Board �f Health t6 determiner they use.TheSystem � � i r must be submiffed
the local Board of Health or other approving authority.A. Facility InforMation,
AddressRight ftont of house, Left/Right rear of.house, Le ft, right side of house Left I
ht side of build'!, r6 in
Left,/Rigk f M eck
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r
Cltyluvve State zip code
Owner,�
AddressOf different fr=location)
City/Town st;n Zip Code
Telephone Number
PumpingB. Pumping, Record
1. Date of
Date Gallons
3. Type.Type-of system.: Tight Tank
Other(describe),
t
., Effluent Tee Filter �r Y yes,,was it,cleaned? Yes N
5. Condition f System:
6, System Pumped By.-
1.Bates7on.
Narne Vehicle License Number
Bateson Ehte[prlses Ina
Company
f
rcontents-were
a
Lowell
r
Sign Ul Date
i
. Pumping r