HomeMy WebLinkAboutSeptic Pumping Slip - 296 BERRY STREET 5/22/2018 mon lfhl f IU :` air
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ln§.Record
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CAForm 4
l•4i;: UM DEFIARI W
®EP has provided this form`for use-by local Boards of Health. Other forms maybeused, 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 ferrh they use.The System Pumping Record must be,submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of house, Le Iggrea�of house, Left 1 right side of house, Left/
Right side of building, Left 1 Right front of building, Left/Right rear df building, Under deck
dress
Cityrrown State Zip Cede
2. System owner:
Piame'
Address(if different from location)
CiWTown
Telephone Number
1. ®ate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ® Yes No,
5. Condition of System: „` C�”
AS
6: System Pumped By:
Neil.Bateson P5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca " wl� contente,were disposed:
G�-S a Lowell Waste Water
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