HomeMy WebLinkAboutSeptic Pumping Slip - 623 OSGOOD STREET 4/24/2018 Commonwealthf Massachusetts
City/Town ofSyi . 1(3
' ing.Record
Fir
®EP has provided this form for us&by local Boards 'of Health. Other forms may'be'used,but the
information-must be substantially the-tame as that provided here. Before using.this form,check with your
loc6l 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.
adlity Information .
1. System Location: Left htwft`'`�r f h uoh se `deft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rigft r�on -o buiiditlg, Left/Right rear of building, Under deck
Address c
Citylrown State Zip Cade
2. System Owner:
game'
Address(if different from location)
CI own State/, C 0 8
Telephone plumber +`
/
PuMpIng R-peord
1. Cate of Pumpingoat$ 2. Quantity Pumped: Gallons
3. Type-of system: (l Cesspool(s) eptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes 040 if yes, was it cleaned? ® Yes ® No,
5. Condition o tem:
6. System Pumped y:
Nell.Bateson • F5821
(dame Vehicle License Number
Bateson Eiaterprises Inc
Company
T, Locaticontents•were disposed:
GLS: e Lowell Waste Water
sign a Houle Cate
t5form4.doa•06/03 System Pumping Record Page 1 of 1