HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BEECHWOOD DRIVE 9/8/2020 - commonwealth of Massachusetts
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RECEIVED
z Lt Cit//Town 01
System
Form 4
TOWN
HEAL H DEPARTMENT
R PEP has Provided this for m,fioC else by local Boards of Health. Other farm
information must be substantially the same as that provided here. Before Using nayt��used local Board of Health to determine the fo but the
the local Board of Health or other approving they use.The System Pumping g %form, checit With your
authority. P g Record must be submitted to
(�a�6Q6fy Q�u�®rra�aafflon
Important:
When fitting out: 1__ item LorsBtl
r6rms on the _ on: :,11'
computer,use -
.only the tab key
Address-w
to moveyour
cursaF do fiot
use the rt:lum city/Town
key. State
2. System Owner: Zip Code
�ab
Name S ✓I C
r Q. R Address(ifdPfs'erentfrom location)
City/foum _
state Zip Code
cr7cP- �5 ?— �J53
Telephone Number
Be Pumpini. Ric Iorld
-1)O
1- Date of pumping
Date 2. Quantity Pumped: LIDO
3. Type of system: Gallons
❑ cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
" Effluent Tee Filter present?,Z yes
❑ No If yes,was it cleaned? Z yes ❑ No
5. Condition of system:
6. System Pumped By:
Name Vehicle License Number
rrtir ZG kS SC�a�rG
Company
7. Location where contents were disposed:
GL97D
Signature of Hauler Date
t5form4.doc°06/03
System Pumping Record Page•I of I
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