HomeMy WebLinkAbout- Septic Pumping Slip - 270 SOUTH BRADFORD STREET 7/2/2019 »w
Commonwealth of Massachusetts
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H Pumplon Record
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Form 4 AW IO E
1111EX"m DERARTMENT
providedDEP has i r use.by local Boards 6f-Health. Other formis may'be'u'sed, but the
inform
t be substantially the 'same as that provided here. Before using Ahis form,Check with your
l l Board of_ Healthystem Pumping Recordl to
the local Board of Health or ot her approvingauthority.
Y mation
As Faciflot Infor '
System
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sit of , house, , righti � ,
Rightibuilding, _ r i llh , r ' it k
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Address
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Cityfrown State Zip Code,
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., System Owner,
Frees from location)
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cityfrown Stater
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TelephoneNumber
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. _ 1
Pumping
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1. Date of Pumping 2.
u
r Pumped:ty
DateGallons
3. Typo-of sy�teft E] Cesspool(s) Cjol�Qpfic Tank El Tight Tank
Other(describle):
4.
Effluent Tee Filter present? Yes 0 If yes, was it cleaned? "es N�
. Condifion of System:
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; System Pumped By:
Nell.
Name Vehicle U
Company,Batesoin
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re contenterweredisposed:
Lowell Wasto Water
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Date
�. 8/ '