HomeMy WebLinkAbout- Septic Pumping Slip - 475 WINTER STREET 6/4/2019 «i 1
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Commonwealth of Massachuseffs
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AI'system Pumping Record
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Form 4
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PA
DEP has provided this for usel;by local,Boards of,Health. Other form may beused,but ther
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Health must be substantially the tame as that provided here. Before using Ithis
locif Boardof u submitteo to
the local Board of Health, r approving authority.
A. Facility InforMation
1. System Rid Left of, s � ` �� side o se, Left
Right side of � �,� id"" ' " cif building, Under deck
Address
ofty rown Stag Zfp Code
. System Owner.,
e
Name'
Address(if different from to
CilwTbwn
za
cov�
Telephone umber
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B. Pumping Record,
. Date of Pumping
� Qu' 'lyPumped: Ali
3. ons
y - i - k Tight
Other(describe):
e
Effluent4.
i t nth Y yI was it c . Y6s No
5. di Ca
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6.
System Pumped Byli
Nell. apt 2
Name Vehicle License Number
, Ina,
Company
w Lo 4',ere contents.were di
Lowellater
Ild
EM
4-In
Sign H bul Date
t6fbrrn4.doojh 06/03 System Pumpingr