HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 8/22/2015 Commonwealth of Massachusetts
City/Town of
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System tem Pumping-Record
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Form 4
DEP has provided this formlor 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. Facill.ty, Information'/-��
1. System Location: Left/Right$bMi&hc u§s%jrRight rear of house, Left right side o*f house, Left/
Right side of building, Left Right ���Left/Right rear of building, Under deck
Address
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1
City/Town state Zip Code
2. System Owner.
Name*
Address(if different from location)
cityrrown State.1w Zip Code
14—
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Telephone Number
.B. Pumping Rpcord
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1. Date of Pumping Date 2. i Q�uan ty Pumped: Gallons
3. Type•of system. r] Cesspool(s) ept le Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep C9- o If yes, was it cleaned? r-1 Yes ❑ No,
5. Condition of System:
6; System Pumped By.,
Nell.Bates7on - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatiog e C ontents-were disposed:
G S
U 7-c
,LS-Q Lowell Waste Water
41
e
4Signe Haule Date
0=4.dot-, 06/03 System Pumping Record•Page I of I