HomeMy WebLinkAboutSeptic Pumping Slip - 7 SOUTH CROSS ROAD 12/28/2016 Commonwealth f Massachusetts
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A ' i �/TownCd:..; ".
Sp4tem Pumping.Record
Form 4
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®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 form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
. Fact0ty. Information
1. System Location: Left/Right front of douse, Left/Bight rear of hour;L 0-/right ,R'of h uo , Left/
Right side of building, Left/Right front of buildidg, Left 1 Right rear of building, Under deb
Address
city/Town state Zip cods
2. System Owner:
Name
Address(if different from location)
cityrrown ' Stale. zi _Ca(ie ;
F Telephone Number �M
.B. Pumping Rqcord
i
1. Date of Pumping oats 2. Quantity Pumped: Gallons
. Type-of system: El cesspool(s) eptic Tank Ej Tight Tank
Other(describe):
4. Effluent Tee Sifter present? E] Yep ".lca If yes, was it cleaned? 0 Yes Igo,
5. Condition of.System:
6: System Pumped By:
Nell.Bat can 1-5321
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo ti r contents were disposed:
L S. Lowell Waste Water
-gig—nAtuha Hhule Date
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