HomeMy WebLinkAboutSeptic Pumping Slip - 476 GREAT POND ROAD 7/12/2016 Commonwealth Of Massachusetts
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Form 44 o ;
CEP has provided this form for use=by local Boards of Health. Other forms may 6'
information must be substantially the same as that provided here. Before using.this form, che3 k with your
local Board of Health to determine the farm 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; Le /Right front of house, Le 9 �..�ight teas Jr,Left/right side of house, Left/
Right side of building, Left/Right front of building, L building, Under deck
Address
.City/Town Stat�e6l
Zip Code
2. System Owner.
Name*
Address(if different from location)
City/Town State Zip Code
�..
c � R
Telephone Nlimber
Pumping ,Record
1. Date of Pumping ( 2. Quantity Pumped:
Date Gallons ,.
3. Typ of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe): ' '
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
� 0
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAtu I fe I Haute Date
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