HomeMy WebLinkAbout- Septic Pumping Slip - 195 OLYMPIC LANE 6/4/2019 y�alrmr CIS)"
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Ith of Massachusefts
Commonwea
Uty/Town of
System
ry Pumping
111111,11
�1 �I I q �U% 1,,
I n��� w �� ,N:r
41Is
Form 4
DEP has rwl'ded this form for u- y l cards , l � r for a used,but
information,, s , '
k with your
loci card f Health 6 determine the for* they use. lard Pumping Record must s I itte
the local Board Health or other approvIng authority.
A. Facility InforMatlon
i
, System Location: Left nt. oof Left R1g,hti
Right side of building, Right fr6nt of buildifig, i µ building, Under
Address
UIIN15
Cf owe state Zip Cod
2:1. System
1
Name t
t
Address,Of different from
i Own
Telephone Number
B. Pumping Oeclord -------
1. Date of Pumping Date . Gallons
Cesspool(s) Jge`pft`IcT a�n k Tight Tank
Cj Other�r(describe).-,
Y Effluent Tee,Fifter presen V
Y. ■f yes, was i I
j
s OA9060
I
...' Condiflon of -.
7
ystem Pumped
yI,
I
Nell
Name i
Vehl'cle UlcenseNumber
Bateson
Company
u
contentswere disposedI
Lowell. y
PumpinglRecorda Page 1, of I