HomeMy WebLinkAboutSeptic Pumping Slip - 399 SUMMER STREET 8/28/2015 Commonwealth of Massachusetts
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D„r klf City/Town of
S * tem Pumping Record
YS ?0
Form 4
DEP has provided this form'for use;by local Boards of Health. Other forms may-tie*6tiid;'b.bf i1hel”
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
1. System Location: Left KI Gl �t f�i6nt Left/Right
Le ht fi6nt of hous u t rear of.house, Left/right side o"f house, Left/
Left I RIO 0
Right side of building, Left/ ig o uildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State- Q� a
Telephone Number
.B. Pumping Rpcord
1. Date of Pumping Yale �2.�Qjuinfity Pumped: Gallons
Septic 3. Type•of system" ❑ Cesspool(s) 1c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes F-1 No,
5. Condition o System:
6; System Pumped By.
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo *. neTe contents were disposed:
7GLLS-b Lowell Waste Water
FignAhie I Haule Date
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