HomeMy WebLinkAbout- Septic Pumping Slip - 11 BRIDGES LANE 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form
4
CEP has provided this form for use-by local Boards of Health. Other forms maybe'used,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. Facifity InforMation
1, System Location: Left/Right front of house, WOW rear of hous, Left./right side of house, Left I
Right side of building, Left Right front of building-,tW/Rl§ff—reaarr of building, Under deck
-Ad—die-is-
Cityfrown state zip code
2. System Owner.
Name'
Address(if different from location)
City/Town State-F-i Zip Code
Telephone Number
® Pumping Kecord
9. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: [] Cesspool(s) 0-9-6—pi-ic Tank 0 Tight Tank
E] Other(describe):
4. Effluent Tee Filter present? D Yes 3--N-o If yes,was it cleaned? El, Yes E] No
5. Condition of System-
6. System Pumped By.
well.Bate Ton F5821
Name Vehicle Ucense Number
Bateson Enterprises Ina
Company
7. Lo ' . e contents-were disposed.,
L
G,I S1. Lowell Waste Water
S
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Sign a Hh4ule Date
t5fbrm4.doe-06/03 System Pumping Record•page 1 of 1