HomeMy WebLinkAboutSeptic Pumping Slip - 410 SUMMER STREET 6/11/2018 Commonwealth u RECEIVED
City/Town of
Form 4
CEP has provided this form for use-by local Boards bfHealth. Other forms may be'used,but the
Information-must be substantially the tame as that provided here. Before using Ahis form,Check with your
local Board of Health to determine the form they use.The System Pumping Record roust be submitted to
the local Board of Health or other approving authority.
• J
A. FacMty 1nf®rr'at10n
1. System Location: Left/Eight front of House, igF ohous. , Left./right side of house, Left
Right side of building, Left/Eight fr6nt of bui ing, Left% 'igft rear of building, Under deck
Address .t rr t ,4J�`-°'t., c'. _...�,�„}•�J�`'
Citylrown 4 state Zip Code
2. System Owner
Name'
t
Address(if different from location)
City/Town ' State' -t ,•.,Zip Code
f
Telephone Number
i
1. ®ate of Pumping nate 2. Quantity Pumped: Gallons `
4
3. Type-of system: ® Cesspool(s) Septic Tank El Tight Tank '
[� Other(describe):
4.. Effluent Tee Filter present? ® No If yes, was it cleaned? es ® Na
' 5. Condition of tenni:
r
6: System Pumped By:
Neil.Batesoo F5621
Name Vehicle License Dumber
Bateson Enterprises Inc,
Company
7. Location w e contents-were disposed:
WHIMe
Lowell Waste Water. . .........
Sigdate
Mbrm4.dor.-06/03 System Pumping Record Page 1 of 1