HomeMy WebLinkAbout- Septic Pumping Slip - 37 OLYMPIC LANE 10/31/2018 Ed-
Commonwealth of Massachusetts
City/Town of
„« Sys
tem Pumplingr ; ra
Form 4 HEY,f KI
CEP has provided this form for use=by local Boards of Health. Other forms maybe'used,but the
information,mint be substantially the erne 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 mint be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of douse, Left 1 h rear of ho , Left/right side of house, Left 1
Right side of building, Left/Right front of buildirg, i ig rear(if building, Under deck
Address
Citylrown 7> 7 State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Sta# �.,.i �- Cad®
Telephone Number
.B. Pumping lRecord
1. Cate of pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: E] Cesspool(s) eptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? EEJ Yes No if yes, was it cleaned? ® Yes El No
5. Condition of System:
6. System pumped 6y:
Nell.Bates7on F5821
Name Vehicle License Dumber
Bate on Enterprises Inc-
Company
7. Lo a contents-were disposed:
Lowell Waste Water
Sign51S.
Haul Cate
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