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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 VEST WAY 7/31/2020 : Commonwealth of Massachusetts `�, City/Town of JUL 312020 System Pumping Record Form 4 ��� ® 0� HEALTH DEP has provided this form for use-by local Boards of Health. Other forms may be used,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 i ht front of hou 'Left/Right rear of house, Left/right side of house, Left Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Citylrown v State�1 Zip Code 2. System Owner. Name' V�p Address(if different from location) CitylTown Telephone Number 13. Pumping record 1. Date of Pumping Dam 2. Quantity Pumped: Gallons 3. Type-of system: ❑ cesspool(s) 9-8 ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©IN If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ca V\ 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locationjw bere contents-were disposed: G L S Lowell Waste Water sign We qt Hbulfflu Date t5fomr4.doa 06/03 System Pumping Record•Page 1 of 1