HomeMy WebLinkAboutSeptic Pumping Slip - 86 FULLER ROAD 7/23/2018 Commonwealth u 1"'ZECEUVE
City/Town of
Sy.i " Pumping-
Record
CEP has provided this forfri for use-by local Boards 6f-Health. Other forms may be'used,but the
information must be substantially the same as that provided here. Before using.this form,cheek with your
local Board of Health to determine the form they use.The System pumping Record must be submitted to
the loom Board of Health or other approving authority.
A. Fac[Pty. InforMation
1. System Location: Lc./Right front of douse, Left/Right rear of house, Left I right side of house, Left f
Hight side of building, Deft/Right front of building, Left/Right rear of building, Under deck
Addrass
City/Town state Zip Code
2. System Owner. c�,
Address(if different from location)
city/Town Slate Code
Telephone Number
1. Cate of Pumping Date 2. Quenu Pumped: Canons
3. Type-of systerri: ElCesspooi(s) eptic Tank 0 Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yep o If yes, was it cleaned? Yes El No,
" 5. Condition of System:
6: System Pumped By:
Nell.Bateson F5621
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lotkmere contents-were disposed:
Lowell Waste Water j
wa
l - CL
F
Sign ifhuEe Tata
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