HomeMy WebLinkAbout- Septic Pumping Slip - 130 HEATH ROAD 9/21/2018 Commonwealth of Massachusefts .
Cit /Town of .
�. ytern Pumping,Record
01,
Form 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.th€s form,c'heck with your
local Board of Health to determine the forth they use.The ystenn Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility, information
I. System Location: Left/Right front of MousePeRIght'W8_rof,:h:ouse eft/right side of house, Leftt
0 Right side of building, Left/Right front of buLeft/ tg rar d building, Under deck
Address
Cityrrown state Zip Cede
2. System Owner: i
Name*
Address(if different from location)
citytrown State- Zip Cada
Telephone Number ,
r
a - 17 f
1. Crate of Pumping crate 2. Quantity Pumped:
Gallons N
3. Type-of,system: ® Cess ocl s) Septic tic Tank �_ight Tank ,.
p C
er(describe):
4. Effluent Tee Filter present? E] Yes 5 /No If yes, was it cleaned? Yes ® NQ
" 6. Condition of System:
6: System Pumped By:
Nell.Bates'ort F6321
Name Vehicle License Number
_Bateson Enterprises Ina
Company .
7. Locatipaw re contents,were disposed:
C LAD
Lowell Waste Water
sign a hthuie Crate
tMrm4.doc•06/03 System Pumping Record.Page 1 of 1
