HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 BOSTON STREET 7/13/2020 I
Commonwealth of Massachusetts RECEIVE
City/Town of 3& 13
020
System Pumping Record vRvW00\4
. Form 4 p g ����TH DEPARTMENT
DEP has provided this form for use=bY local Boards of Health. Other forms may be used, but the
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information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrim they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Location: Le /Right of house Left]Right rear of u e i side o
1. System Left/ ht front g r house, L ft/right f house Left/
Y 9 9 ,
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
9 9� 9 9� 9 9.
Address
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Cityfrown State Zip Code
2. System Owner. �(
Name
Address(if different from location)
CitylTown State- Zi Code
Telephone Number
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B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) [:J-��eptic Tank ❑ Tight Tank
❑ Other(describe):
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4. Effluent Tee Filter present? ❑ Yes [-No If yes, was it cleaned? ❑ Yes ❑ No
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5. Condition of System:
6. System Pumped By: W ';
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G L, p Lowell Waste Water
Sign a Naul Date
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