HomeMy WebLinkAbout- Septic Pumping Slip - 19 BOXFORD STREET 6/13/2019 A tCommonwealth ofMassachulsefts
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System Pumping Record
Form 4
DEP has provided Mis form for use;;by local Boards of"Health. Other formis may'be'Used,but the
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i here. r irk k with your
local l rSubmitted
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the
local Board of Healthr other approving authority.A, Facility 1
F
Information
frontSystemi Location: Left Right M r �ibuilftg,
" ' house, !
Right side R�r h front i lin"i � fight rear Under deck
Address
cityrrown State Zip Cody
. System Owner.
5
Address
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(1fdifferent from to
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C,*ItWj,lown Statercs
Telephone m
.B. Pumping Record
Othernil
1. Date of Pumping Date 2. Qu6nfily Pumped,: Gallons ------
3- TypIe-olf systemb Gesspool(s) M-mmlmml�pflc Tank D Tight Tank
El
(describe).,
Filter4., Effluent Tee r nth" 0, Y If y , was it cleaned? EJ Yes E] No,
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1
System m l
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Nei I.BlatesbQL. F5821
Name Vehicle License Number
Company
. Locatio, ,here content&were disposed:
Lowell Waste Water
Date
EF
Pumping a e Page 11, of 1
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