HomeMy WebLinkAboutSeptic Pumping Slip - 72 PADDOCK LANE 5/1/2017 wCommonwealth of Massachusetts
t own of Fl ECEIVED.
Form
®EP has provided this form for use-by local Boards of Health. othi orm maybe`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 forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
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A.
Facfldty Information
1. System Location: Left/Right front of douse, Left/Right rear of house, ftp/ri h "ia g of _,.
'h® •, Left J �
Right aide of building, Left/Right front of building, Left/Right rear of building, Under deplc
Address 1� i
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Cit yyv[r wdn State Zip Carle
2. System Owner W .
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Name
Address(if different from location)
City/TownMete Z* Code
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7Telephone iJumber r"
® Pumping Rqcord
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1. Date of Pumping o�te 2. Qudntity Pumped:
gallons `
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3. Type-of systerra: El Cesspool(s) t 8�ptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yes [9-Ko If yes, was it cleaned? E lies El No.
' S. Condition of System:
I
6. System Pumped 6y:
Neil.Bat bn - F5821
Name Vehicle License Number
Bateson Eriter�rises Inc
Company t
7. Location where contents-were disposed:
S. Lowell Waste Water
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ign a Him a pate F
t5form4.dcc®06/03 System Pumping Record•Page 1 of 1