HomeMy WebLinkAboutSeptic Pumping Slip - 1491 TURNPIKE STREET 4/24/2018 m n !tMassachusetts �
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City/Town own of
System Pumping-Record
Form 4
DEEP has provided this form*for use-by Kcal Boards 6f Health. Other forms may'be'tased,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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
_Facfl , I f r ! n
1. System Location: Left/Right front of House, Left I Right rear of house, Left/ sl a of Nous�Left/
Right side of building, Left/Rig6t front of building, Left/Right rear of building, Under enc
Address 4J CUN
� 4
(:ity/"town state Zip Cotte
2. System Owner:
Name'
Address(if different from location)
City/Town State- 1rde
A .
'telephone Number
i
p , ling v.,._ pc t'
1. bate of Pumping nate 2. Quantity Pumped:
Gallons
3. Type-of system: El Cesspool(s) epile Tank EJ Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes o if yes, was it Cleaned? ElYes ❑ No,
' S. Condition of System: �
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License dumber
Bateson Enterprises Inc
Company
7. L , tl ere contents,were disposed:
S. Lowell Waste Water
Sign a Hhule Cate
tftrmCdoo-08/03 System Pumping Record•Wage 1 of 1