HomeMy WebLinkAbout- Septic Pumping Slip - 161 BRIDGES LANE 1/8/2019 I
Commonwealthof Massachusetts
C City/Town f
System 'u pin r
c I
Form 4
®EP has provided this forth 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 to
the local Board of Heath or other approving authority.
1. System Location: Left/Right front of House, a fight ar of hotbuilding,
Left/right side of house, Left
Right side of building, Left/Right fr®nt of building, Left/R1gh rear Under deck
Address
vim-
cityf"rawn State zip Code
2. System Owner:
Name'
Address(if different from location)
citylrown stat �i ado
Telephone Number
Pumping Kecr
1. bate of Pumping hate 2. Qtt� City Pumped:
Gallons e
3. Type-of system: ® Cesspool($) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? D Yes o If yes, was it cleaned? D Yes ® No
5. Condition of System:
. .System Pumped By:
Nell.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a contents-were disposed:
lI L S: Lowell Waste Water j p
Sign a hiauie date
0orm4.doce 06103 System Pumping Record d Page 1 of 1