HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 HOLLOW TREE LANE 7/16/2019 b
Commonwealth of Massachusetts
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Pumpfong.Record
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Form 4
DEP has
Provided forte for 4 "y localbf"Health. Other fore may� , � e
informagon,must be:substinfli tame thatprovidedhere. Beforeusingthis form,check with your
loeil Board of Health t6i s
determine formi ,they
.,TheSystern may,
g Record must be aubmifte�d tc)
the local Health or other approving authority,
A. Fact0ty Inforrhat,i,on,
} System : . i front ' h reara of � � , righti hour , Left I
Right side of building,,
011"uIlding, Left,
ght rear cif building, Under deck
Address
City/Tow1n, stag Zip Code
2. System Owner.,
T
Address(if differentfrom,i o
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M N*
elephone Number
B. Pumpill,nig ke,cord
1, Date of Pumping 2. Quiknlfi�(Pumped:
Date
Apw
N y
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Gallons,
w �
l k Tight Tank
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Other(describe):
4, Effluent Tee Filter r nth yes, was,it, ? Yes E] No,
ia
,,. SystemPumped By,.
ll.,Batesft
Name Vehicle License Number
Bateson r Inc-
Company
w
r disposed.
µG,,L Lowell Waste Water - w
13U Date,
Sol,n a f
x System Pumping Recordo
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