HomeMy WebLinkAbout- Septic Pumping Slip - 895 FOREST STREET 10/19/2018 1�zL;CVEIVED
..�L Commonwealth of Massachuseffs 7
City/Town
ER
OF 1140'"Al"[)OV
System Pumping Record 'TO I � DIWCITW
Form 4
CEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information-must be substintially the same 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 to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right frontpf house, Left/Right rear of house, Left.fthf�ldge_qf hour ,Left Under
dec
Right side of building, Left I Right front of building, Left/Right rear of building, Under dep
Address
76iii/Wown State Zip Code
2. System Owner
Name'
Address(if different from location)
City/Town C
5's
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system* E] Cesspool(s) aWp-r—ic Tank [I Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes 0 If yes, was it cleaned? El Yes E] No
M1W
5. Condition of System: �Jo<-
6. System Pumped By:
Nell.Bates-on F5821
Name Vehicle Manse Number
Bateson Enterprises Ina
Company
7. Locati Contents-were disposed:
L 7
M SIQ Lowell Waste Water
481gne Date
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