HomeMy WebLinkAbout- Septic Pumping Slip - 68 CRICKET LANE 1/8/2019 Commonwealth f Massachusetts
w City/Town of
W° System Pumping Record
Form 4
®EP has provided this form for useQby local Boards of Health. Other forms may be'used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your
ioc6i 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 InforMation
Right side of building, Left/Right front of building, Left/Right rear of building, Under
9. System Location: Left/Right front of House, Left/Right rear of house, Left/ d-of had eft
g 9 9 9 g g, der deck
Address
6- e��-
Cityfrourn State Zip Code
2. System Owner
Name'
Address Of different from taxation)
City/7awn State Zip Code
'telephone Plumber
a Pumping Record
Ct-. '
1. bate of Pumping Date 2. Quantity Bumped: Gallons
3. Type-of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? Q Yes ® No
5. Condition of System:
. System Pumped By:
Nell.Batesan F5821
Flame Vehicle License!dumber
Bateson Enterprises Inc
Company
7. Loca' . pre contents were disposed:
N
G 1.SID Lowell Waste Water
SignAtufs I Hhule Gate
t5form4.doc-06/03 System Pumping Record d Page 1 of 1