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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 119 LIBERTY STREET 12/13/2021 Commonwealth of Massachusetts City/Town of z System Pumping Record Form 4 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 you local Board of Health to determine the form they use.The.System Pumping Record must be submitted tc the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right use, Left/right side of house, Left Right side of building, Left/Right front of building, Left/ ght rea of building, Under deck on the computer, use only the tab I/ key to move your Address � �� cursor-do not Q � �� ,© W \ MA use the return key. _tity/T—own State Zip Code 2. Sy em Owner: Name rertm Address(if different from location) MA City/Town State Zip Code Te ephone Number B. Pumping Record 1. Date of Pumping pate` 2. Quantity Pumped: Gallons I Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present?lam es No If yes, was it cleaned? ❑ es ❑ No 5. Observed condition of component purmp)jd: 5o" , 6. System Pumped By: David Tiney _ Mass F5821 _ Name Vehicle License Number Bateson Enterprises, Inc. Company 7. Locaf n where contents were disposed: LSD Lowell Waste Water - "ate Signature of Hauler Date