HomeMy WebLinkAboutSeptic Pumping Slip - 75 HAY MEADOW ROAD 10/23/2008 Cornmonwealth Of Massachusetts
City/Town Of
System pin cr � � �,��
Form 4
5 N(1)V
a
p Y by p ms ma be sed, but the
in ormation must behsubs substantially the same)as that of
rovi dd lit Other' "� Ir orm, check with your
local Board of Health to determine the form the use. Th a 06iM in Record,must be submitted to
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the local Board of Health or other approving authority.
A. Facility Information
Whpenrfilling out 1. System Location(C;ft,
frWu�nW t ef rear, left side of o-u-
s�eight front, right rear, right side of house.
forms on the
computer, use
only the tab key Address f ,-
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner: p � -
VQ
Name
Address(if different from location)
City/Town State + Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) r] Septic Tank Ej Tight Tank
Other(describe): --
4. Effluent Tee Filter present? 0 Yes U
If yes, was it cleaned? Yes Q No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
SCD _
L anten#s were disposed:
7. Location yy_,ere c7
/ Lowell Waste Water
Auignal-re of H u r Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1