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HomeMy WebLinkAboutSeptic Pumping Slip - 544 SHARPNERS POND ROAD 10/15/2015 Commonwealth of Massachusetts = City/Town of S s .tem 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 your local Board of Health to determine the farm they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility. Information .. a 1. System Location: Left/Right front of house, Left/Rtght'rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address(if different from location) Citylrown State Telephone Number 3 1 r l / B. Pumping Rgcord ,... ., 1. Date of Pumping 2. Quantity Pumped: . Date v,.. Gallons 3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ®14o If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: V 6: System Pumped By: Neil.Batesbn F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Loca -�er contents were disposed: G L S. Lowell Waste Water ... . -Sig—nghfe cit Haulejj Date t5form4.doc•08/03 System Pumping Record•Page 1 of 1