HomeMy WebLinkAboutSeptic Pumping Slip - 427 WINTER STREET 12/28/2016 Commonwealth of Massachusetts 'tiECE '"ED
Form 4 HEALTH DE,
a
CEP has provided this form for use-by local Boards of Health. Other forma may ba bsed, but the
Information-must be substantially the tame as that provided here. Before using.this fora,check with your
local Board of Health to determine the forth 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/Right front of house, Le "gift rear of hou Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Riggs rear df building, Under deck
city/Town state Zip Code
2. System Owner: N
Varna. - _
Address(if different from location) -
Citti/rouwn State i Cade
Telephone Number
k
Pumping
1. Date of Pumping Cate 2. �u� tity Pumped: Gallons
• `A
. Type-of system: El Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
41. Effluent Tee Filter present? D Yep o if yes, was it cleaned? 0 Yes El No,
5. Condition of System: I
6. System Pumped 6y:
Neil.Bateson - F5821
Name Vehicle License dumber
Bate on Enterprises Inc
Company -—
7. Locationrre contents were disposed:
. Lowell Waste Water
Cate
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