HomeMy WebLinkAboutSeptic Pumping Slip - 96 FARNUM STREET 3/12/2018 Commonwealth of Massachusetts V509
a
City/Town of I
Pumping.
Form 4
CEP has provided this form for use-by local Boards of Health. Other forms relay 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 t+o
the local Board of Health or other approving authority.
A. acflyty f f r ti r.
1. 5yster. Location: Loft/Right front of house, Lefti h ar of hou,�, Left/right side of house, Left I
Right side of building, Left/Dight front of building, Left/Right rear of building, Under deck
Address
Cityll'own state zip Cade
2. System Owner: h �V\ �?
Nt.
ame'
Address Of different from location)
City/Town ' State Zi Cade
Telephone Numb
er y
i
.B. Pqmping
ll'
'
1. bate of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: El Cesspool(s) eptiC Tank E) Tight Tank 1.
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of Sy tem:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loc tion w re-epritents,were disposed:
4SIgne
Lowell Waste Water Haul bate
i5form4.docd 06/03 System Pumping Record Page 1 of 9