HomeMy WebLinkAbout- Septic Pumping Slip - 720 FOSTER STREET 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record MNII OF \UH I C1 MIOOVER
Form 4 I EALT�l
CEP has provided this form for us&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 System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility InforMatlon
1. System Location: Leh/Right front of house, Left/Right rear of house, Left 01-g-fibj o house Left I
Right side of building, Left Right front of building, Left/Right rear of building ig �e�rdeo,�nder de 2
Address
Cityfrown state zip code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number
.B. Pumping K-ecord
1. Date of Pumping
Date 2. Quantity Pumped: Gallons
3. Type-of system, E] Cesspool(s) Ej-SeptlicTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumped By:
Nell,Bateton F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. L eg6nft,�,hm- ontent%were disposed:
T Q, Lowell Waste Water
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Sign a Hhulau Date
t5fbrm4.doG-06/03 System Pumping Record-page 1 of 1