HomeMy WebLinkAboutSeptic Pumping Slip - 26 SHANNON LANE 10/28/2016 (2) RECEIVED
Commonwealth of Massachusefts
NOV `I NIti
City/Town of .
S item Pum in -Record E LI LT ��a b
' ,
Form 4
C EP 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 fora, 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 1 Right front of house d6ga,L tig ar of houus ,Left/right side of house, Left/
Right side of building, Left/Right front of b Lefttl rear of building, Under deck
Address _( ,
Cfty/'rown -- State ,Zip Code
2. System Owner. `
Name'
Address(if different from location)
City/Town ` State zip Code
,CC (
Telephone Number
i
r _
.B. Pumping Record
1. Date of Pumping oat 2. Quantity Pumped: Gall.—Ik
3. Type-of system: El Cesspool(s) 0- eS"ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [j-M"a If yes, was it cleaned? El Yes ❑ No
6. Condition of Syst m:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. LoZ'S here contents,were disposed:
: Lowell Waste Water
Sign a cf Haule Date
t5form4.doc•OB/03 System Pumping Record•Page I of 1