HomeMy WebLinkAboutSeptic Pumping Slip - 55 VEST WAY 6/6/2018 FIZECENED
Commonwealth f Massachuseffs
CitKown of
SyMem Pumping,Record �.wiOIDOVER
Form 4
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CEP has provided this form for use=by local Boards of Wealth. Other forms may be'used,but the
information-must be substantially the same as that provided hare. Before using.this form,check with your
local Board of Health to determine the forret they use.The;Systern 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, Left/Right rear of house, Left/right side of house, Left 1
Right side of wilding, Left 1 Right front of building, Left/Right rear of building, Under deck
Address
City/rown state Zip Code
2. System Owner:
I IA
v v1 v
Name'
Address(if different from location)
CitylTown state Zip Code
Telephone Number
b r
B.
Pum
ping Rpcord
1. bate of Pumping oat --44�-- -1' . 6u6ntil�Pumped:
Gallons —t
3. Type-of system. ® Cesspool(s) Septic Tank Tight Tank a
D Other(describe):
4. Effluent Tee Filter present? ® Yes /No if yes,was it cleaned? ® Yes No,
5. Condition of System:
M u!
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
--Bateson Enterprises Inc`
Company
7. Location where contents-were disposed:
OLS Lowell Waste Water
z 0Z
sign a Fibulo Date
t formit.docd 06/03 system Pumping Record m Page 1 of 1