HomeMy WebLinkAboutSeptic Pumping Slip - 192 STONECLEAVE ROAD 6/6/2018 Commonwe ialth of Massachusefts
UWT®Wn of AN 0 H3
I is � �O� kV��f'IH NDOV.'.0;�
Form 4
d���.; �
®EP has provided this for.M for use-by local Boards of Health. tither forms maybe`used,but the
Information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Wealth to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Fad0ty Inform" ation
9. System Location; L /Right fro int of douse, e {Rtgh_rr ea of hoYobuilding,
Left/right side of house, Left/
Right side of building, Left I Dight front of building, Left I kigh rear Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name*
Address Of different from location)
City1rown " Stater e__>
y i pie
f
Telephone Plumber
1
® Pumpling Ptecord
1. ®ate of pumping Date 2. Qu ntity Pumped: Gallons
3. Type-of s stem:
Yp Y. Cesspool(s) eptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yep o if yes, was it cleaned? ® Yes ❑ No,
5. Condition ofs m:
6: System Pumped By:
Nelt Bateson - F'5821
Dame Vehicle License Number
Bateson Enterprises Inc
Company — -
7. Lo dore contents-were disposed:
.
.L Lowell Waste Water
Signirturle phuWuCate
tftrm4.doca 06103 System Pumping Record*Page 1 of 1