HomeMy WebLinkAbout- Septic Pumping Slip - 125 BRIDGES LANE 11/26/2018 Commonwealth f Massachusetts
City/Town of
Systemi r �E �'t
Form 4
CEP has provided this form for us&by local Boards oMealth. Other forms maybe'used,but the
information-must be substantially the tame as that provided here. Before using.this form,c'heck with your
local Board of Health to determine the forth they use.The System Pumping Record must be submitted t,0
the local Board of Health or other approving authority.
A. Facility InforMation
I. System Location: Left
/Right front of house, Left/Right rear of house, �gr*i Under deckhou'.i..w,
.. Left,/
Right side of building, Left/Right front of building, Left/Right rear of build
Address
City/°rown State Zip Code
2. System Owner:
r w* �✓ ;`,
Name`
Address(if different from location)
CiEylTown State "'�`> Zip Code
'telephone Number
® Pumping -eC C
t .'
_ 6
1. }date of Pumping 2. Quantity Pumped:
Date �. Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes allo if yes, was it cleaned? ® Yes ❑ No
S. Condition of System: i �,,.
4 ,
6. System Pumped By:
Dell,Bates-on F5821
Name Vehicle License Number
_ ateson Enterprises Inc
Company
7. Locati ? .ere contents-were disposed:
i"
C L S; Lowell Waste Water
sign a F#hute Date
t5f0rm4.doca 06/03 system Pumping Record.Page 1 of 1