HomeMy WebLinkAboutSeptic Pumping Slip - 85 WINDKIST FARM ROAD 5/22/2018 Commonwelialth of Massachusetts
RECEIVED
City/Town of .
Form 4 'VOWN 01z a � t,JO.IFS IDOVE
HU
Ini
CEP has provided this form`for use-by local Boards of Health. Other forms may be'used,but the
informs, gon-must be substantially the,same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submltte�d to
the local Board of Health or other approving authority.
A. Facility information
1. System Location; Deft/Right front of Mouse, Leat/Right rear of house, Left f right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address --
City/Town State Zip Code
2. System Owner:
Name.
Address(if different from location)
CitylTown Stateri,
�p
! G '
Telephone Number
s Pumping Rpcord
1. ®ate of Pumping sate 2.�ua' ty.Pumped: Gallons
3. Type-of system: Cesspool(s) ; eptjc
Tank ❑ Tight Tank i
Other(describe):
4. Effluent Tee Filter present? ® Yep DINo if yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System: �-
6; System Pumped 6y:
Neil.Bateson - F5821
Mame Vehicle License Number
Bateson Enterprises Inc,
Company
T. Lo�Atlpn re contents-were disposed:
Asign
Lowell Waste Water
*H!3ul Gate
Mrrn4.dooa 06/03 System Pumping Record page 1 of 1