HomeMy WebLinkAboutSeptic Pumping Slip - 100 FOSTER STREET 3/12/2018 Commonwealth of Massachusetts
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M WC1 of
SyMem i I � 4
Form '' .
CEP has provided this form for use.by local Boards of Health.Other forms may be'used,but the
'
information-must be substantially the me as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The$ystern pumping Record must be submltted to
the local Board of Health or other approving authority.
A. FacWty. f r ti
1. System Location: Left/Right front of house, Left/Right rear of hour. L •frig25e=h�ou e LeftRight side of building, Left/Right front of building, Left/Right rear cif building, U
Address
�wI A_ ;Z
City1rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown ' State- , r- Zip Code ;
Telephone Number f�d
Pqmpllng Record
l P wily . r•
1. ®ate of Pumping n t b2. Quantity Pumped: Lallans
3. TypeW system: ❑ Cesspool(s) Qo�pfik Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? ® Yes ❑ No,
. Condition of System:
6: System Pumped By:
Neil.Bates-on F6821
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. L=LLS
contentsrwere disposed:
Lowell Waste Water
Sign vmulej Cate
15form4.doc-06103 system:Pumping Record•Page 1 of 1