HomeMy WebLinkAboutSeptic Pumping Slip - 1060 TURNPIKE STREET 12/13/2016 Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
Form 4
RE CE'
CIEP has,provided this form for use-by local Boards of Health. Other form's may be'.t�Iset,e u
information,must be substantially the same as that provided here. Before using.th�s f�'rm,ch`ec with your
local Board of Health to determine the form they use.The System Pumping R � �� #xub d to
the local Board of Health or other approving authority, Jj Qr
A. Facility Informlation
1. System Location: Righ � t of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front ot building, left/Right rear df building, Under deck
. Address � C.? •�� �'l.s� � ��' t..J � ,:�-``�,`.�`•—
City/Town State Zip Code
2. System Owner.
Name.
Address(if different from location)
CitylTown ' Stattr � d 7 r..1 S ip!
f Telephone Number :'
1
1;
.B. PUrMPing_.RRecord
1. Date of Pumping Date 2. Qua tity Pumped: Gallons
r
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
' S. Condition of System:
6: System Pumped By:
Neil.Bateson F5821'
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca' ta.. re contents-were disposed:
A'. Lowell Waste Water
Sign Date
iformCdocr 06/03 System Pumping Record•Page 1 of 1