HomeMy WebLinkAbout- Septic Pumping Slip - 185 BRIDGES LANE 1/8/2019 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 may be'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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I. System Location: Left/Right front of house, Left/Right rear of house, Left.kr—jgbTj'jq of hous%.Left I
Right side of building, Left Right front of building, Left I Right rear of building, Under deck--'
Address
cityfrown S Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Stater Zip Code
Telephone Number
.13. Pumping Record
1. Date of Pumping 2 uantity Pumped:
Date Gallons
3. Type-of system' E] Cesspool(s) Septic Tank [I Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? F1 Yes If yes, was it cleaned? El Yes E) No
5. Condition of System:
6. System Pumped By:
Nell.Bates*bn F5821
Name Vehicle License Number
Bateso
Company
7. L q a�o" ere contenta were disposed:
,,
Lowell Waste Water
Sign We cfHoulmu Date'
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