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HomeMy WebLinkAboutSeptic Pumping Slip - 41 SUMMER STREET 8/21/2015 Commonwealth of Massachusetts City/Town of S item Pumpin g,R Yecord S Form 4 j . �H' DEP has provided this formlor uset by local Boards of Health. Other forms may be'used, b'but the information-must be substantially the tame 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 I System Location: Left/Right front of house, Left rear of hou Left/right side of house, Left/ Right side of building, Left Right front of building, Left Right r of building, Under deck Address Cityfrown State Zip Code 2. System Owner. 3 Name' Address(if different from location) Cityfrown - St _7,1p Code Telephone Number B. Pumping Rpcord 1. Date of Pumping 2. Quantity Pumped:Date Gallons 3. Type•of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present.? ❑ Yes 0--N--o� If Yes, was it cleaned? ❑ Yes ❑ No, ' 5. Condition of System: V-ek)-Lk 6.- System Pumped By., Nell.Bates-on F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Locati here contents-were disposed: Lo U GLS. Lowell Waste Water 4e aule Sign Date H t5form4.do •06103 System Pumping Record•Page 1 of 1