HomeMy WebLinkAboutSeptic Pumping Slip - 100 SAW MILL ROAD 6/6/2018 Commonwealthof Massachusetts
own ofJUN 011
Cit..
k, Sy6tem Pumping.Record
` Form 4
®EP has provided this form for use-by local Boards of H lth. Other forms maybe'used,but the
information-must be substantially the same as that providedhere. Before using.this form,check with your
local Board of Health to determine the forms they use.The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Factlity, Information,
1. System Location: Lei/Fight front of douse, Left f rear of , left/right side of house, Leff/
Right side of building, Left/Right front of buildifig, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner: _
V V'\
Name`
Address(if different from location)
Citylrown ' Sfr Zi")
p Telephone Number
• i
13.
Pumping c _ \
1. bate of Pumping Cate 2, (Wuantity Pumped: Gallons
3. Type•of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes No if yes, was it cleaned? Yes ® No
' 6. Condition of System: ....
6: System Pumped By:
Neil.Bates7on ' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-wh contents-were disposed:
Lowell Waste Water
Sign a hltul Clete
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