HomeMy WebLinkAbout- Septic Pumping Slip - 149 BRIDGES LANE 10/2/2018 Commonwealth of Massachusetts
City/Town of
OM
®EP has provided this forIm for use-by local Boards of Health. Other forms maybe'used,but the
information-must be substantially the tame as than provided here. Before using.this fora,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. Facility Information,
�
1. System Location: Left/Right front of House, Left ioht r ou a% Left/right side of house, Left 1
Right side of building, Left i Right front of building, Left/Right rear of building, Under duck
Address ��-�1
y
CityCrown State Zip Code
2. System®wrier:
Name'
Address(if different from location)
citylTown State ` � mC Zi�Ctrde .,
_ �
"telephone Number r ��
1. Date of Pumping cote 2. Quantity Pumped: � Gallons "���ti
3. Type-of system: El Cesspool(s) eptic Tank Tight Tank
E] Other(describe):
4. Effluent Tee Filter present? E) Ye. o If yes, was it cleaned? E Yes El No,
' S, Condition ofSystem:
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locati whe contentsrwere disposed:
L t S. Lowell Waste Water
4neR D Date
t5form4.doom 08/03 System Pumping Record m page 1 of'I
