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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 657 FOREST STREET 11/19/2019 RECEIVED Commonwealth of Massachusetts N�V 19 Zoe = City/Town of �N AN�'VER SOWN OF NDEpAR1MEN� System Pumping Record Form 4 DEP has provided this form for use=by local Boards of Health. Other forms may beused, but the information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of house, Left kfi ht side of house;Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Un er ec Address ,/ City/Town state Zip Code 2. System Owner. Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date ' Quantity Pumped: Gallons l �� 3. Type of system: ❑ Cesspool(s) [3 Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? © Yes ❑ No If yes, was it cleaned? Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatiop-where contents were disposed: S. Lowell Waste Water Signitule CrHaul Date t5form4.doa 06/03 System Pumping Record•Page 1 of 1