HomeMy WebLinkAboutSeptic Pumping Slip - 851 JOHNSON STREET 1/12/2016 Commonwealth of Massachusetts
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City/Town of
System Pumping-Record
Form 4 1
DEP has provided this form for use=by local Boards of Health. Other forms may be*used, but the
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information must be substantially the same as that provided here. Before using.this form, check with your f
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
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1. System Location: Left/Right front of hous �r"In�g., !got-,ear o-hous M'` Leff/right side of house, Left/
Right side of building, Left/Right front of b eft/R ig rear of building, Under deck
Address
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_ C secr
City/Town State ;'ip'Code"
2. System Owner.
Name
Address(if different from location)
Citylrown t Stater ip Code
Telephone Number
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B. Pumping Record
1. Date of Pumping Date 2. Qua City Pumped: Gallons
3. Type.of system: ❑ C spools) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yap ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6: System Pumped By:
Neil.Mason F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w ere contents were disposed:
Lowell Waste Water
Sign fefkauieV Date
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t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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