HomeMy WebLinkAbout- Septic Pumping Slip - 70 WINDKIST FARM ROAD 9/24/2018 Commonwe,91th Of Massachusefts
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Pumping. r r� ��
Form 4
CEP has provided this formfor use�by local Boards cif Health. Other forms maybe'used,but the
inforrmation-must be substantially the tame as that provided here. Before using.this farm,check with year
local Board of Health to determine the forth they use,The,Oystem Pumping Record must be submitted t®
the local Board of Health or other approving authority.
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FacflUty ! for l
I. system Locati Pig fr o ous`e�' Left Right rear of house, Left/right side of house, Lei
Right side of bui �ngg,Teft/Right front of building, Left/might rear of building, Under deck
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Address r
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityflawn State, � c�' ip Code 5 S 2 i
'telephone Number +'
Pumping Pqmping kecord _ .
1. Date of Pumping oats 2. Quantity Pumped: Gallons r
3. Type-of systerri: Cesspool(s) eptic Tank 0 Tight Tank
® Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? [j Yes ® No,
t
Condition of.System*
Uv,,,
6: System Pumped By.
Neil,Bates7on ' F5821
Name Vehicle bttcense Number
Bateson Enterprises Inc'
Company
7. Lo 'here contents,were disposed:
� Lowell Waste Water
Sign Haute Cate
t5fbrm4.doc-06/03 System Dumping Record d Page 1 of 1