HomeMy WebLinkAboutSeptic Pumping Slip - 544 SHARPNERS POND ROAD 7/2/2018 RECEIVED
Commonwealth
wJUN 18 2010
FQrm 4 ��� HEAL r
CEP has provided this for rri for use-by to F, " #" of Health. Other forms may ba bsed,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 form 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: Let/Right front of douse, Left/ �t rear of hour. Left/right side of house, Leff/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
city/town state Zip Code
Z. System Owner:
Name'
Address of different from location)
city/Town S#at ' ip Coda
'telephone Plumber r �
P
1. ®ate of Pumping 2. Cuar�tipumped: F V
Date Gallons
r
3. Type-of system; ❑ Cesspool(s) eptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present'? El Yep No If yes, was it cleaned? ® Yes El No,
. Condition of System*
6: System Pumped By:
Neil.Batesion - F5821
Fame Vehicle License dumber
Bateson Ehte rises Inc,
Company
7. Locatio a contents.were disposed:
Lowell Waste Water
Sign Haul ate
t6fbrm4.doe6 06/03 System pumping Record.page 1 of 1