HomeMy WebLinkAboutSeptic Pumping Slip - 1 GRAY STREET 4/24/2018 Commonwealth Of Massachusetts
4
® n o ',
ePumpon. 0,Record
Form
®EP has provided this forrni for use-by local Boards of Health. Other forms may ba bsed, but the
information-must be substantially the same as that provided here. Before usin .this€orm.,check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
® ["Ry. Information
1. System Location: Left/Right front of douse, Left41hi rear of hour; Left/right side pf house, LeftRight side of building, Left/Right front of buildingear of building, Under deck
Address
tlty/`rown State Zip Code
2. System Owner:
Mame"
Address of different from location)
Cityrrown • StaterZip Code
telephone Number
i
® ire r �.
1. date of Pumping crate 2• Quanti Pumped: Gallons
r
3. Type o€systerrt: ® Cesspool(s) Septic Tank Tight Tank ,•
® Other(describe):
4. Effluent Tee Filter present? El Yes ® No if yes,was it cleaned? ElYes: ® No,
6. Condition of Syste ll
6; System Pumped By:
Pfeil.Batesran F6821
Name Vehicle License plumber
Bateson Enterprises Inc,
Company
7. Locatio ere contents-were disposed:
L S Lowell Waste Water
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el
Sign a I-MauleruCate
tMnn4.doe-06/03 System Pumping record a Page 9 of 1