HomeMy WebLinkAboutSeptic Pumping Slip - 61 ESSEX STREET 6/1/2016 It Massachusetts
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Form 4
CEP has provided this formi for use=by local Boards of Health. lather 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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. In i
1. System Location: Left/Right front of house, Le lkight rear of houso,"Left/right side of house, Left/
Right side of building, Left/Right front of buildirg,-Left%"Right-rear cif building, Under deck
Address r
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CWTown State Zip Code
2. System Owner: }
Name.
Address(if different from location)
Citylr'own state", Zip„Code ;
f Telephone Number
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. Pumping Rpcord
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1. Date of Pumping Date 2. Quantity Pumped: Gallons y�
3. Type-of system: ❑ Cesspool(s) kw• -86p—tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System'
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6.- System Pumped By:
Neil Bates-on ` F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location�where contents were disposed:
-L,S.D Lowell Waste Water
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Sign
RHaule
Date
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