HomeMy WebLinkAboutSeptic Pumping Slip - 40 DUNCAN DRIVE 4/24/2018 Commonwelaithof Massachusetts
Form 4 A.
®BP has provided this form for use-by local Boards of Health. tither forms may 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 forrn they use,The;System Pumping Record must be submitted to
the local Board of Wealth or other approving authority,
A. Factilty, Information
1. System Location: Left/Right front of house, Left!Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityrrown State< ip Cod
Telephone Number
Y Pumping cr
1. Date of Pumping hate �. ntity Pumped:
Gallons
3. Type-of system. El Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee'Filter present? r] Yes a<o If yes, Was it cleaned? ® Yes ® Na
6. Condition of System: ('
6: System Pumped By:
Nell.Bates7on ' F'6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca n vui e content%were disposed:
C
LSQ LS: Lowell Waste Water
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Sign a Maul Cate
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