HomeMy WebLinkAboutSeptic Pumping Slip - 600 FOSTER STREET 4/24/2018 Clwn of
sy.4tem Pumping.Record
CEP has provided this for for use�by local Boards 6f Health. Other forma may be'used, but the
information,roust be substantially the tame 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 to
the local Board of Health or other approving authority.
A. cli . InforMation _
1. System Location: Left/Right front of Mouse, Left rear of house; Left/right side of house, Left 1
Right side of building, Left 1 sight front of building, Left I Fright rear of building, Under deck
Address
6,nD
Citylrown State Zip Code
2. System Owner:
Name
Address Of different from location)
City/Town state C,
'telephone Number
t
r'
Pgaipling Ricord L4 U�
1. ®ate of PumpingDere . Quantity Pumped: Gaitons y
3. Type-of system: [] Cesspool($) 4 title T k ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? ff No,
5. Condition of 5 stem:
6: Systent Bumped By:
Neil.Batesbn F5821
Name Vehicle License Dumber
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
r Lowell Waste Water
Sign a H luie Date
t5fnrm4.doo^06/03 system Pumping Record•page 1 of 1