HomeMy WebLinkAbout- Septic Pumping Slip - 61 WINDSOR LANE 9/24/2018 Commonwealth of Massachusetts
Al 01
Cjt�/Town of
S*em Pumping.Record
®EP has provided this form`for use-by local Boards of Health. Other forms maybe bsed, but the
information-must be substantially the same as that provided hare. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted fc)
the local Board of Health or other approving authority.
A. FacMty Information
1. System Location: Left/Flight front of house, Left I t rear of hoias Left/right side of house, Left
Right side of building, Left I Right front of building, Left/Flight rear of building, Under deck
Address
1
Cityfrown State Zip Code i
2. System Owner
n-,
' Name'
Address(if different from location)
Cityfrovwn ' State• Zip Code
Telephone Number
t.
Pumping C
1. Plate of Pumping Date t � � �2. uiintily Pumped: �
Gallons����
3. Type of system: Cesspool(s) Septic Tank ® Tight Tank k
0 Other(describe):
4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? ® Yes ❑ No,
6. Condition of System:
e,0 _ 1
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bi3teSon Ente Piles Inc,
Company
7. Location where contents-were disposed:
G 5: Lowell Waste Water t
Sign Ftaule date
t6forrn4.dor,-06/03 System Pumping Record*Page 1 of 1