HomeMy WebLinkAbout- Septic Pumping Slip - 135 ACADEMY ROAD 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumping r
Form 4 idc:��
®EP has provided this form for use.by local Boards of Health. Other fortes maybe`used, but the
information-must be substantially the game as that provided here. Before using.this forth,check with your
local Board of Health to determine the forth 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 front of Mouse, Left igh ear a�Oreaoru6f
Left/right side of house, Left/
Right side of building, Left/Right fast of building, a tguilding, Under deck
Address
cityrrown ` 5 to Zip Code
2. System Owner:
Name'
Address(if diff6rent from location)
Cityla own State Zip cede
telephone Number
13. Pumping Recr
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ cesspool($) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [I Yes 3---go If yes, was it cleaned? ❑ Yes ❑ No
6. Condition of system: , O
c_
6. System Pumped By:
Neil.Mason F5821
Name Vehicle E icense Number
_Sateson Mate rises Inc-
Company
T. LocW7iohhhere contents-were disposed:
Lowell Waste Water
Sign a t� uie bate
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