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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 BRIDGES LANE 10/12/2021 : Commonwealth of Massachusetts RE���VED City/Town of System Pumping Record Form 4 ®WN®fiM©�PPR(MEN� N�A1- 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 AGhjt�fmi , 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 L V I Co ieJ Cityffown State Zip Code 2: System Owner. Name' Address(if different from location) CitylTown State- Telephone NumberC ltl� B. Pumping Record 1. Date of Pumping pate 2 Quanti Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [y, No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: - ti. c (� F582'f Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatignv4iere, contents were disposed: AowQ Waste Water h—7-2)�al SignAltjie 9t H I i Date Norm4.doc-06/03 System Pumping Record•Pagel of 1