HomeMy WebLinkAbout- Septic Pumping Slip - 63 BRADFORD STREET 9/24/2018 Clt�/Town of
Sy,4. tem Pumping." 1 E
Record
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bEP has provided this form'for use-by local Boards 6f Health. Other forms may be'used,but the
information-must be substantially the tame 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. Facill.ty. I f r i o ,.
I. System Location: Left/Right front of House, Le Fight �; .eft• right side of house, Left/ f
Right side of building, Left/Right front of buiidini Le�t/Right rear of building, Under deck
Address
Cityfrown State Zip Coda
2. System Owner:
Name'
Address(if different from location)
awrown ' Stater i Ccrd�
`telephone Number
1
rtl
u rftecord
1. bate of Pumping Date 2. Quantity Pumped: Gallons T
3. T e•of s stern:
yp y. El Cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? � Yet o If yes, was it cleaned? Yes ❑ No
" 5. Condition of System:
1
B: System Pumped By:
Nell.Bateson - F5821
Name Vehicle,License Number
Bateson Enterprises Inc-
company
7. Lo o her contents-were disposed:
L S: Lowell Waste Water
Sign a Hbul Date d
s
t5fomn4.doc^08/03 System Pumping Record page 1 of 1