HomeMy WebLinkAbout- Septic Pumping Slip - 31 VEST WAY 9/24/2018 Commonwe.alth of Massachusetts
City/Town o
RecordSystem Pumping.
Form 4
MP has provided this form for use-by local Boards ofhlealth. Other forms may be'used,but the
Information'must be substantially the Larne 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. clf . Informiation
1. system Location: Left/Right front of house Lett igh ar o house; Left/right side of house, Left/ t
Right side of building, Left/Right front of boil trig, Left/might rear of building, Under duck
f
Address
CitylTown State Zip Code
2. System Owner: ) *
Name'
Address(if different from location)
City/Town - '. State' Zip Code
"telephone Number
i
Pumpling lRecord ;
1. bate of Pumping rate 2. Qucantity Pumped: Gallons
3. T e•of s stern: 4'yp y. [� Cesspool{s) eptlC Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? [l Yes if yes, was it cleaned? ® Yes ❑ No,
` . Condition of.System: j
o �
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License dumber
Bateson Enterprises Inc-
Company
?. Lo contents-were disposed:
G S. Lowell Waste Water
Sign a Hhule Clete
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