HomeMy WebLinkAboutSeptic Pumping Slip - 129 CHRISTIAN WAY 3/22/2016 Commonwealth of Mass
i wn of RECEIVED
S item Pumping,Record
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Form
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CEP has provided this form for usetby local Boards i ff 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/Righ rot Moue a /Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of bui Ing, Left/Right rear of building, Under deck
Address
QAl
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' Sta ip Coda_
Telephone Number
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B. Pum in - JRpcor T
1. Date of Pumping 2. Quantity Pumped:
Date Gallons y —`
`t
3. Type-of system: ❑ Cesspool(s) a6eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ONO If yes, was it cleaned? [ es ® No
5. Condition of Sy
r-A L -
- / ' - cam.
6: System Pumped By: "
Nell.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locati wwh contents were disposed;
G L S'. Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/08 System Pumping Record.Page 1 of 1