HomeMy WebLinkAbout- Septic Pumping Slip - 32 CRICKET LANE 10/19/2018 ED
Commonwealth of Massachusetts Ivr
C' own of
Sy.4tem Pumping. ec r• .
Fqrm 4 0n 0nJ0EqP,?jMFNI
®EP has provided this form for use:by local Boards of Health. tither forms maybe bsed,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.
W. -Facility. I f r ti
1. System Location: Le /Right front of Mouse, Lett rear of hour Left/right side of house, left
Right side of building, Left 1 Right 66rit of building, Left/ rear of
building, Under deck
Address C..,�-.-'�� �._,�•�'� �.�...X.,hh`�`�_w �' '�✓�. ,.w.C�"�/.
CiwTown state Zip Code
2. System Owner: �
Name.
Address Of different from location)
CityTrown State <i _d,_®
Telephone Number
(G .afff
1. Cate of Pumping Date "r 2. Quantity pumped: Gallons .�`
3. Type-of system: El Cesspool(s) epti Tank 0 Tight Tank
[] Other(describe):
4. Effluent Tee Filter present?, Yap _wo If yes, was it cleaned? ® Yes ® No,
1
5. Condition of System:
cA
g: System Pumped By: 1
Nell.Bates-on F6821
Name Vehicle License Number 3
Bateson Enterprises Inc
Company
7. L tie here contents-were disposed:
. j
C B Lowell Waste Water 1
• F
Sign a Haul Coate
Worm4.docd 06/03 System Pumping Record a page 1 of 1