HomeMy WebLinkAbout- Septic Pumping Slip - 285 REA STREET 1/8/2019 Commonwealth of Massachusetts
City/Town of
N. I
Pumping.-N System
r
Form 4
®EP has provided this farm for use-by local Boards of Health. tither forms may be*used, but the
informatlon must be substantially the Larne as that provided here. Before using.this farm,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 f r ti®
1. System Locatlor
Ong,
/Ri ral;�t�f Fiau , Left/Right rear of house, Left/right side pf house, Left/
Right side of bulLeft/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner:
Flame'
Address(if different from location)
City/Town State4 c �Zi od.
Telephone plumber
® Pumping r
1. ®ate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool($) ❑ ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 04es ® No If yes, was it cleaned? es ❑ No
S. Condition f System:
6. System Pumped By.,
Nell.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo ontents-were disposed:
L S Lowell Waste Water
Sign 6°lout Cate
t5form4.doc®06/03 System Pumping Record®Page I of 1