HomeMy WebLinkAboutSeptic Pumping Slip - 124 SAW MILL ROAD 12/13/2016 Commonwealth f Massachusetts
RECEIVED
• i n of
System i Record
Form 4 TOW1 OF NOR r e1ANOOVE ;
HEA 161 C•.rU'F N
®EP has provided this fora for use-by local Boards of Health. Other forms maybe'used, but the
information must be substantially the tame as that provided here. Before using.this form,Check with your
to 'l Board of Wealth to determine the fora they use.The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility. Inf r °a tQ �D
I. ,System Location: Left/Right front of douse, RlgE ar®f h otJS , Leff/right side of house, Leff 1
Right side of building, Left/Riglit fr®nt of buildirg, Left/Right rear of building, Under deck
Address � �� - • •
AICAf
City/Town State Zip code
2. System Owner:
Name'
Addraas(if differerdt from location)
city/1 awn State dip de
"telephone Number r„
Pumping r
t . r
°I. Date of Pumping Date 2. Qu6ntity Pumped- Gallons
. Type-of system. Cesspool(s) ptic Tank D Tight Tank ,.
Other(describe):
4. Effluent Tee Filter present? Yep if yes, was it cleaned? ® Yes No,
5. Condition of System:
6; System Pumped By:
Nell.Batesan F5321
Name Vehicle license Murnber
Bateson Enterprises Ina
Company
7. Lo t W =contents-were disposed
- r
.LS..LSQ Lowell Waste Water
SignAtufa cf Haule Date
t5form4.doc®08/03 System pumping Record page 1 of t