HomeMy WebLinkAbout- Septic Pumping Slip - 22 TIFFANY LANE 6/4/2019 j Ith of Massachusefts
Commonwea
RECEIVr
arri'tW
CKY/Town of
1"A"Y
Form 4
6
S tem Pumping ecord,
YS
V II�IIQ�@ II�II/ III ( �% YI G DEP has p.rovided this form for use;,by local Boards of-Health. Other formt may,beused,but the
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Inform substinfially the tarn tarne,as that providedhere. Before us .this form,check wi� your
locil Board of Health to determine the fonn' they use. Pumping tte t
the local r Health r other approving authority,
J
As
Facility InforMation
Sys,tem Locatlon: Left Right front of house, Left R!19
hit rear of hiousp,qe 'ghl ouse, Left Iqj 0@6 Offoulse,
sideRight building, i rbuilding, Lefti rear - Ui ., U
�Address r
n w
Cityrrown Stalte ZIP C e
2. System Owners
e
Address from location)
Cityrrown w �)�
dip Code
Telephone r
B.,
1, Date of Pumping Date 2. Qu6nflty Pumped: Gallons
3. Type-of system.* El Cesspool(s) U--86�pflc k n
OtherE] (describe),.-
4.,
1
I . Yes No
. Condifion
.1
Nelt System Pumped By:
7
Narne Mahicle License Number
Bateson Ehteg?rises Ina
Company
7. Location x contents-were
. Lowell Waste,Water
5'O'IZZ�,7
S Houle- Date
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