HomeMy WebLinkAbout- Septic Pumping Slip - 41 CEDAR LANE 9/24/2018 o on ith of Massachusetts
City/Town o
Sy�tem Pumpin§-Record
L.. Form 4
. 4
DBP has provided this forrri for use-by local Boards of 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 form they use. The;System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facflity In orMation
f
�r
1. System Location: Left/Right front of house FI-Rlg T—e;W Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
.� All
CRY/Town State Zip Code
2. System Owner: °•�
Name'
Address(if different from location)
Citylrown Stater I Zip Code
Telephone Number ">
Pumping c®r
1. Plate of Pumping pate 2. t�ut�Pumped:
Gallons
3. Type-of system: El Cesspool(s) (3-9e tic Tank Tight Tank
El Other(describe):
4. Effluent Tee Fitter present? D Yes o if yes, was it cleaned? ® Yes No
` 5. Condition of System:
14`�r �
6. System Pumped By:
Neil.Bates-on F6821
Name Vehicle Utcanse Number
Bateson Enterprises Inc-
Company
I
7, Locab h contents-were disposed: 1
.LS Lowell Waste Water
Sign Haul Date j
Mrma.dow 06/03 System Pumping Record Page 1 of 1