HomeMy WebLinkAbout- Septic Pumping Slip - 659 FOREST STREET 1/8/2019 Commonwealth of Massachusetts
City/Town of
f
System
a
Pumping Record
Form 4
®EP has provided this form for use-by local Boards of Flealth. Other forms may be'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 In for Mation
1. System Location; Loft/Right front of house, Left/Right rear of house e - i167�elcr'
eft/
Right side of building, Left/Right front of building, Left/Right rear of bulk.
Addres&2z�
Cityfrown State Zip Code
2. System Owner; �.
Name'
Address(if different from location)
Cityfrawn ,State- t7 F7
'telephone Number �✓
® Pumping -ec r
1. Gate of Pumping Date 2. Quantity Pumped;
Gallons
3. Type-of system. Cesspool(s) eptnk Tight Tank
Other(describe);
4. Effluent Tee Filter present? ® Yes o �_ If yes, was it cleaned? ® Yes ❑ No
5. Condition of stem:
V)
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Rateson Enterprises Ina
Company
7. Locati a contents-were disposed;
C 1. Lowell Waste Water
d �
Sija hthula Sate
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