HomeMy WebLinkAbout- Septic Pumping Slip - 196 SUMMER STREET 1/7/2019 &Z Commonwealth of Massachusetts RECMVED
City/Town of
System Pumping Record
Form 4 JOW�1 01 F�40�J, MID OVER
HEN
MP has provided this form for use-by local Boards of Health. Other forms maybeused, 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 form they use. The$ystem Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Igh(fro-i.iEM' eft Right rear of house, Left/right side of house, Left I
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address [Cl. 0
Cttyrrown t state Zip Code
2'. System Owner
Name'
Address(if different from location)
Citytrown stater
Telephone Number
.B. Pumping lRecord
1. Date of Pumping Z Quantity Pumped:
Date Gallons
3. Type-of system: E] Cesspool(s) G-Septic Tank E3 Tight Tank
E3 Other(describe):
4. Effluent Tee Filter present, a es [] No If yes, was it cleaned? E3-Yes-�No
5. Condition of Sys
6. system Pumped By: f
Nell.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wher ontentts.were disposed:Lowe',W.jste�*
L �7 a
Lowell Waste Water
0 Haule
Sign ule Date
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