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HomeMy WebLinkAboutSeptic Pumping Slip - 27 OAKES DRIVE 11/10/2015 Commonwealth of Massachusetts City/Town of System Pumping.Record Form 4 DEP has provided this formlor use-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 1. System Location: Left/Right front of house, Left I ht Mff ofjj�, Left right side of house, Left Right side of building, Left Right front of building, Left/Right rear of building, Under deck Address Cityfrown State Zip Code 2. System Owner: Name Address(if different from location) cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Q_ifity Pumped: Gallons Date ----71- 3. Type-of systefff. ❑ Cesspool(s) B-6eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present.? ❑ Yep a'go` if yes, was it cleaned? ❑ Yes r_1 No ' 5. Condition of System: 6.- System Pumped By: Nell Batesbn F5821 _Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: j a Lowell Waste Water _65_nku.Te qf HauleV Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1