HomeMy WebLinkAboutSeptic Pumping Slip - 76 EVERGREEN DRIVE 6/6/2018 Commonwe.afth of Massachuseffs MEWED
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JUN 0 8
i GSY.4tem Pumping.Record
Form 4 TO�M_l O 'NCgi11M,00
VS
qYAV aEF1pJ1 UMNU
CEP has provided this form for use-by local Boards of Health. Other forma may'be'used,but the
information-must be substantially the tame as than provided here. Before usin .this farm,check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority,
A. Facflity. 1 f r ti {
1. System Location: Left/Right front taf Mouse, Left/Right rear of house, Left;/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under dock
Address ]
Citylrown Mate Zip Code
2. System Owner:
Name'
Address Of different from location)
City/Town State l .. p,Code
4 c ;
"telephone Number
t
Pqm:ping Rpeord _
1, bate of Pumping crate 2• Quantity Pumped: Capons
3. Type-of system: ® Cesspool(s) otic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes o If yes,was it cleaned? ❑ Yes ® No
5. Condition of System: ` - }
; System Pumped By.,
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents-were disposed:
L Lowell Waste Water
Sign a Hhul Date F
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