HomeMy WebLinkAboutSeptic Pumping Slip - 33 CRICKET LANE 10/15/2015 I
Commonwealth of Massachusetts
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City/Town of
M° yMem Pumping.Record w :
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Form 4 ��0�t6v;grl
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DEP has provided this form far 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/Right front of hous g76high ar`of housey Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear a building, Under deck
Address
,�.,�, � �„.N � �... ..,..... •and 53
Citylrown state Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zi Code
Telephone Number
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B. Pumping Record
1. Date of Pumping bate 2. Quantity„Pumped: Canons
3. Type-of system: ❑ Cesspool(s) [3-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3 No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: .,
KC/1AA_
• 6: System Pumped By:
P
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca,#on°where contents were disposed:
C L S: Lowell Waste Water
S ign#e Haule Date
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