HomeMy WebLinkAboutSeptic Pumping Slip - 145 CRICKET LANE 4/24/2018 P
Commonwealth of Massachusetts
Z 16
City/Town own f . R �
° SyMem Pumpoing.Record
Farm 4
CEP has provided this form for use-by local Boards®f Health. Other forms may be'used,but the
information,must be substantially the same as that provided here. Before using.this fornrl,check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. FactFact0ty, Information .
1. System Location: Left i ht fr Left 1 Right rear of house, Left-1 right side of house, Left
Right side of building, Left/ ig(#front of building, Left/Right rear of building, Under deck
Address �� �--4�•�'�..�,'`,,.��i'� '•` �%"���� ...."4 �/��..., „-.-..
city/Town State Zip code
2. System Owner
Address(if different from location)
city/Town ' ;Stat u , ipC de
r
'telephone Plumber +'3
J
. Pumping Rpeord ,
1. Date of PumpingDate 2. Quantity Pumped: -
- Gallons
3. Type-of system: ® Cesspool(s) [_9'' epi tic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? [l Yes o if yes, was it cleaned? El Yes E] No
5. Condition of System:
6: System Pumped By:
Nell Bates7on ` F6821
Name Vehicle License Dumber
atesart ante rises lnc
Company
7, Lo re contents were disposed:
L UP- Lowell Waste Water
.� � f �%
Sign a Hanle Date
Obtm4.doc•06/03 System Pumping Record•page 1 of 1