HomeMy WebLinkAbout- Septic Pumping Slip - 130 HAY MEADOW ROAD 1/8/2019 Commonwealth ®f Massachusetts
CityfTown o
up
System PumpingRecord
Form 4
®BP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
informatiorr must be substantially the Same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The Systern pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Leh/Right front of douse, Left/Right rear of house, Left./right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address c
City/rown state Zip code
2. System Owner
Name,
Address(if different from location)
City/Town State Zii�Code
'telephone number
13. Pumping Record
` A
1. Date of(Pumping date 2. Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? El Yes ❑ No
6. Condition of Syste� �� r ) r''-`~_ i7rz�' z
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises inc-
Company
, Locatio ontents-were disposed:
,L S: 1 Lowell Waste Water
Sign a Haul e Date
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