HomeMy WebLinkAbout- Septic Pumping Slip - 49 CARLTON LANE 6/13/2019 Comonwealth
Massachusetts
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System, Pumpino Record
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Form 4 ',
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DEP has provided th,Is form for useoby
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local Boar rmis
RecordInformation-must,besubstintially the t;ame as that provided here. Before using.this form,check with your
1=61 Board of Health to determine the for M' they use.TheSystern Pum Ing
the local Board of Health or other,approving
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Facility
rightI. System Locaflon: Left/Right front i
Righti building, fit ,,nt rear buildirig, r r . i � w
Address
Cityfrown state Zip Cody
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System Owner, 0, C,elk 1��liq`*\
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Name
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Telephony Number
Type-of.B. Pumping Pecord CT
1, Date of Pumping Date 2,. Qu a'ntity Pumped,,-,- Gallons
3. c Tank Tight Tank
E] Other(dje=dbe),
4. Effluent Tee Filterpresent'?, Yes 0.01ro Yes El No
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5. CiSystem:�
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�, System Pumped By-.,
Neil.
Narne Vehiclei umber
In
parry
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disposed.Lowell Waste Water
Sign e Hhul Date
d000 06/03 System Pumping Record