HomeMy WebLinkAboutSeptic Pumping Slip - 80 WINDKIST FARM ROAD 6/11/2018 Commonwealth of Massachusetts
a
Cl . /Town
Sy4item Pum pling.Record
Fonn 4
CEP has provided this form for use-by local Boards of Health. Other forms may'be'used, but the
Information must be substantially the same as that provided here. Before using.this form,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 Health or other approving authority.
A. Facility, Information
1. System Location /Righ o t pf house, Left/Right rear of house, Left/right side of house, Left/
Right side of buil 1 Left/Right front building, Left/Right rear of building, Under depk
Address
city/Town State Zip Code
2. System Butner:
dame'
Address(if different from location)
City/Town ' Stat`�e✓/�(yJ (q)/ Zip Code ;
�v_
Telephone Dumber
® Pumping Record
Cy
1. ®ate of Pumpingcare - -- 2 Quantity Pumped:
Cellons
3. Typa-of,systeft Ej Cesspool(s) E9 Septic Tank E) Tight Tank
Cather(describe):
4.. Effluent Tee Filter present? El Yep No If yes, was it cleaned? ® Yes ® No,
5. Condition of System:
6. System Pumped By:
Neil Bateson F'5821
Name Vehicle License Number
_Sete�on Er*tergarises Inc
Company
7. Location where contents-were disposed:
_L Lowell Waste Water
Sign Rout
to�a c
tfttm4.doc6 06/03 System Pumping Record m Page 1 of 1