HomeMy WebLinkAboutSeptic Pumping Slip - 242 FOSTER STREET 3/22/2016 Commonwealth f Massachusetts
City/Town of MAR 21), ?o ll
" Pumping. r a ,�4 � dM OV;R
Fir i �wt� :
CEP 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 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/ ht r �rear eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/ llding, Under de ck
Address
City/Town State Zip Coale
2. System Owner.
Name
Address(if different from location)
City/Town ' State Z* rye i 1
7 V) ,3
Tele hone Number i°4
. Pumping Record
1. Orate of Pumping Date Z. Quantity Pumped: Gallons r�
3. Type of system: ❑ Cesspool(s) ❑- eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes Na If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System•
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
LS. Lowell Waste Water
c4ygm.
Sign a Haule Date
t5forrM.doc-06/03 System Pumping Record+Page 1 of 1