HomeMy WebLinkAboutSeptic Pumping Slip - 93 WINTERGREEN DRIVE 5/22/2018 Commonwealth of Massachusetts :NED
i o nof .
.. MAY 201
SyMem Pumping,Record
Form 4 T004 OF
CEP has provided this ford for us&by local Boards of Health. Other forms may be'used,but the
Information-must be substantially the same as that provided here. Before using.this fort.,check with your
local Board of Health to determine the form 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 Location6' /Right t of how; Lett/Right rear of house, Left/right side of house, Left/
Right side of buil g, Left/Right front of building, Left/Right rear of building, Under deck
Address
tea.
citylrown date Zip Code
2. ,System Owner:
Name'
Address(if different from location)
city/Town Stat ip Code
Telephone Number
Pqmping
_ r .
1. ®ate of Pumping Dat 2. Quantity Pumped:
Gallons ,
3. Type-of system: Cesspool(s) U-Septic Tank Tight Tank i.
El Other(describe):
4. Effluent Tee Filter present? Yep r if yes, was it cleaned? ❑ Yes ® No.
5. Condition of.System:
r
6: System Pumped 6y:
Nell.6atesbn • F5821
Name Vehicle License number
_Bateson Enterprises Ina
Company
7. Location here contents-were disposed:
L S Lowell Waste Water
Sign a Hbule bate F
t5form4.do(-06/03 System Pumping Record a Fuge t of I