HomeMy WebLinkAboutSeptic Pumping Slip - 962 TURNPIKE STREET 12/4/2017 RECEIVED
Commonwealth of Massachusetts
mm City/Town of .
WI4 Of:NORTH ANDWER
System Pumping.record HFLU,i DEc lUi Nr
Form 4
y�
CEP has provided this form for use-by local Boards of Health. Other forms maybe used, but the
information•must be substantially the tame as that provided here. Before using.this form,check with your
focal Board of Health to determine the forrin they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority. f
1
A. Facility. Informlation
1. System Location: Laft/Right front of douse, Left Ri��trear of ho�cdf
Left/right side of house, Left0 Right side of building, Left/Right front of building, a rearuilding, Under deck
l
• Address
Cit^Wn State Zip Code
2. System Owner:
Name'
Address(if different from location)
CityfTown ' Star Zip Code
fr
'telephone Number
j
.. 1
. Pumping Record
Dl '7
1. Cate of PumpingDate 2. Quantity Pumped: titans
3. Type-of system: ® Cesspool(s) �PticTank ❑ Tight Tank r.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sys e
6. System Pumped By:
Neil.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
y. Locatio w e contents-were disposed: _ •
L S: Lowell Waste Water
F
Signa Haule Clete
l5form4.doc•06103 System Pumping Record•Page 1 of 1