HomeMy WebLinkAbout- Septic Pumping Slip - 300 FOSTER STREET 9/24/2018 Commonwealth of Massachusetts
City/Town of .
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CE•R has provided this forfri for use-by local Boards of health. Other forms maybe 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. Factlity. Information
..
I. System Locatlon: eft igh =ron
, Left/Right rear of house, Left/right side of house, Left J
Right side of bui gam';Left/ ilding, Left/Right rear of building, Under deck
Address
cityfrown - _ State Zip Code
2. System Owner: AAa „
Address(if different from location)
City/i'awn ` `. State•�j p Cod ,
'telephone Number
.m
Pumpling
1. bate of Pumping cote 2. Quantity Pumped: .
Gallons _
3. Type-of system': (l s�Cess ool tic Tank p ( ) � e p Tight Tank
Other(describe):
4. Effluent Tee Filter present? a? If yes, was it cleaned? s No,
' 5. Condition of System:• `
C,�.,
6, System pumped By. \V
Nell.Bateson F5821 f
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Logati ontentsrwere disposed:
LS Lowell Waste Water(4G,
Houle Cate
t5forrn4.docb 06/03 System pumping Record®page 1 of 1