HomeMy WebLinkAboutPumping System Record 3/13/2017 Commonwealth Massachusetts
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DBP 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 fora,check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted t j
the local ward of Health or other approving authority.
A. Factlity. Inform ti
I. System Location: Luft J( igl t_ftoxlt of hoes Left J Right rear of house, Left/right side pf house, Left!
i Right side of building, Left/Right front of buildidg, Left J Right rear of building, Under deck
Address
Cityffown State dip—Coda
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2. System Owner.,
NJame'
Address(if different from location)
City/Town � '. �5tn �.� i— ode
�'
F 'telephone Number
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® PumpingRecord �+
1, date of Pumping . Qu6nti Pumped:
Date Gallons
. Type-of sYsteal. Cesspool(s) a tic Tank � Ti ht Tank
Other(describe):
4. Effluent Tee Filter present? Yes 9-14x'.. If yes, was it cleaned? El Yes Ej No,
' 5. Condition ofste
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6. System Pumped By:
Nell Bat bn - F5821
Name Vehicle License Number
Bateson Fhte rises lroc )
Company
?. Locatio .v e contents were disposed:
L S: Lowell Waste Water i
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