HomeMy WebLinkAboutSeptic Pumping Slip - 67 CRICKET LANE 12/28/2016 FIECEIVE
Commonwealth
Z 6Z 0 16
CiWown of
SyMem Pumping.. rw: � �r
Form 4
CEP has provided this form for uses by local Boards of Health. Other formi3 may used,but the
information-must be substantially the tame as that provided here. Before using.this form,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. Faclifty. Infor ti®n
I. System Location: Loft/Right front of house, Lett/Right rear of house, O right`i e oar hou , Left J
Right side of building, Left/Right front of building, Left f Right rear of building, Under deck
Address
dyfrawn Mate dip Code
2. System Owner: }.
Name'
Address(if different from location)
city/"rown " State Zip Cede ;
Telephone Number ,
a
Pumping Record
1. Date of Pumping �. 2. Quantity Pumped: Gallons
. Type•of system. Cesspools) eptic Tank El Tight Tank 1.
El Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? E Yes NQ
. Condition of System:
VC)
6; System Pumped Sy:
Nell.6at bn F5821
Name Vehicle License Nturnber
Sateon Enterprises Ina
Company
7.iSign ere contents were disposed:
'. Lowell Waste Water
Houle Date
t5form4.doc,06/03 System Pumping Record Page I of 1