HomeMy WebLinkAboutSeptic Pumping Slip - 190 MILL ROAD 8/13/2014 Commonwealth f Massachusetts
W City/Town of
S item Pumping Record
YS
For
y
CEP has provided this form far 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 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/Right rear of house, Left riM"hT de of hoy` , 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)
Cityfrown State ,Z Code
Telephone Number
B. Pumping Record W
1. Cate of Pumping Date . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ® es ❑ No.
5. Candition stem:
6. System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loqiq-wkTre contents were disposed:
G L S. Lowell Waste Water
Sign t e Haule Date
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