HomeMy WebLinkAboutSeptic Pumping Slip - 79 VEST WAY 5/1/2018 Commonwealth of Massachusetts
W itt�/Tow n o
t Pumping.Record
� (.nr �� ��� � �� ��.�
Form 4
t.J N�f
DECD has provided this forfni for use-by local Boards of Health. Other fords 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 form they use.The,System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. cl# Inform' sition
ig
ar s � Left/right side of house, Left/
1 Right side of building, Left I Right font of b , Ing, Lefft regh t r �6f building, Under deck
Address c U ri
city/Town State Zip Code
2. stem towner:
y ) � �
Name
Address Of different from location)
City/Town ' Stat Zip de
14
Telephone plumber
7
B.
'n
g�
1. Date of Pumping Date 2. Qudntity pumped: Gallons €�
3. Type-of system•: El Cesspool(s) eptic Tank. [] Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? Yes o If yes,was it cleaned? ❑ Yes ❑ Na
` 5. Condition of Systenn:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Dumber
Bateson Enterprises Inc
Company
7. Lo w here Contents-were disposed:
�.S Lowell Waste Water
. F
Sign a Mule Date
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