HomeMy WebLinkAboutSeptic Pumping Slip - 230 FOREST STREET 5/1/2017 q i own of
ro.
Pumping.
Form 4
a '
®EP has Provided this fora for use-by local Boards of Health. Other forms may •used,but the
information-must be substantially the same as that provided here. Before using.this forrh,check with your
loc l 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. cll , Information
_. .front of hoe..,
1. System Location: Left/Right ftp ,m ota� w)Left/Right rear of horses, Left•/right side of house, Left
Right side of building, Left]Pi ffik"'fr6h�t of buildirig, Left/Right rear of building, Under deck
Address ... a
rty/Town Mate - Zip Come
2. System Owner:
Fume'
Address(if different from location)
oityfrownState-/.", %de
t "telephone dumber
7
. Pumping
17 43
1. bate of Pumping Date 2. Quantity Pumped;
Gallons
3. Type-of systerw. Cesspool(s) 0_ ptic Tank Tight Tank
Other(describe):
4.. Effluent Tee Filter present? ® Yep 9m, b" ' If yes, was it cleaned? Yes No,
5. Condition of Syste -
6. System Pumped 6y:
Nell.Bateson • F5821
Name Vehicle License Number
Bateson hterprises Inc•
Company
?. Locationw
� h e contents-were disposed
Lowell Waste Water
Cy 7v t
Sign a Hiule Date
t5form4.doc-06/03 System Pumping Record-Mage 1 of"E