HomeMy WebLinkAbout- Septic Pumping Slip - 52 BANNAN DRIVE 1/8/2019 Commonwealth of Massachusetts
City/Town ofsr
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 same 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 to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location- Al frdfifous
Q Left I Right rear of.house, Left/right side of house, Left./gl ronh
g; tt of.buildirig, Left/Right rear f building, Under deck
Right side of builds Left- ig 6 in
Address
.......... B
CRY/rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
ciijt-rown State
Telephone Number
,13. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: Cesspool(s) 9-S-e_p4ic Tank 0 Tight Tank
[j Other(describe):
4. Effluent Tee Filter present? E] Yes o If yes, was it cleaned? 0, Yes El No
6. Condition of System,
6. System Pumped By:
Neil.Batesbri F5821
Name Vehicle License Number
Bateson Enterprises Ina
company
7. Loc4u'orfvher contenter were disposed:
Lowell Waste Water
4 LYa;H 13 u 4le
Sign Date
t5fbrm4.doL-06/03 System Pumping Record a Page 1 of 1