HomeMy WebLinkAboutSeptic Pumping Slip - 60 LONG PASTURE ROAD 6/6/2018 Commonwealth f Massachusetts
I own of
n. e Mem Pumping.Record
Form 4
®EP has-provided this forrri for use-by local Boards of Health. Other forms may'be used,but the
Information-must be substantially the tame as that provided here. Before using.this fora,check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facloty. for fi
1. System Location: Le./Right front of Mouse, Left/Right rear of houso eight Ide of hou e, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deg
. address
CWTown State Zip Code
2. System Owner.
Name'
Address(if difffiimt from location)
Cityfrown State , ,,,Zip ad!
'telephone Number
i
e
• /,a
„Pqmping
RecordM
1. Date of Pumpingsate 2. Quantity Pumped:
Gallons
3. Type-of system: El Cesspool(;s) epti Tank El Tight Tank
Other(describe):
e4. Effluent Tee f=ilter present? ® Yes o if yes, was it cleaned? Ej Yes ® No,
' 5. Condition of system:
6. System Pumped By:
Feil.Satesbn F'6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafionwhere contents-were disposed:
Me
Lowell Waste Water
ihul C113te f
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