HomeMy WebLinkAbout- Septic Pumping Slip - 67 CRICKET LANE 1/7/2019 Commonwealth of Massachusetts "
w City/Town of
System Pumping Record ��,
Form 4
CEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facifity Inform' aflon
1, System Location: Left/Right front of douse, Left(klljti�rear of h+�uss eft/right side of house, Left J
Might side of building, Left/Right front of building, Left/Right rear of building, Under deck
City/rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/rown State` Zi Code
r&?--
Telephone plumber
B. Pumping r
1. bate of Pumping pate 2. Quantity Pumped: Gauons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes Edo if yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System pumped By:
Nell.Batesori F5821
Name Vehicle License Number
_Bsteson Enterprises Inc
Company
7. Location where contenterwere disposed:
ftHoul
Lowell Waste Water
Sign Cate
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