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HomeMy WebLinkAboutSeptic Pumping Slip - 285 REA STREET 12/2/2015 i Commonwealth of Massachusetts City/Town of . System Pumping-Record Form 4 DEP has provided this form far usevby 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 forth 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; eft/)Rig Aff nt of lious� Left/Right rear of house, Left/right side of house, Left/ Right side of buildg;'Left/ ghif fron�of building, Left/Right rear of building, Under deck Address CitylTown State Zip Code 2. System Owner: Name' i ,°�> Address(if different from location) citylrown ' • State,— ._, Zip Code Telephone Number I .B. Pumping Record , m 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? ❑ es © wNo If yes, was it cleaned? 0-"Yes ❑ No, 5. Condition of System •w.. 6: System Pumped By: Neil.Batesbn F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location S. here contents were disposed: G L Lowell Waste Water Ira Sign We Haule Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1