HomeMy WebLinkAbout- Septic Pumping Slip - 65 EQUESTRIAN DRIVE 1/7/2019 Commonwealth of Massachusetts
Y City/Town
System Pumpina Record
Form 4
®EP has provided this form for use.by local Boards of Wealth. tither forms may used,but the
Information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Wealth to determine the form they use.The System Pumping Record must be submitted to
the local Board of health or other approving authority.
A. Facility f rm' atlon
1. System Location: Leh/Right front of house, Left/Right rear of house, rights!,j1 8 0jj grssA Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown V Stag Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State- Zip Code
'telephone Number
13. Pumping
1. Date of Pumping Date 2. Quantity Pumped:
Capons
3. Type-of system: ® Cesspool(s) epile Tank (l Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? ® Yes ® No
5. Condition of System: n
0' r�^�`-G � V1,
6, System Pumped By:
Nell.Batesorr F5321
Name Vehicle License Dumber
_Bateson Enterprises Inc-
Company
7. Locati where contents:were disposed:
7�L Lowell Waste Water
Sign a Haute Date
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