HomeMy WebLinkAbout- Septic Pumping Slip - 42 JAY ROAD 1/8/2019 Commonwealth of Massachusetts
a City/Town o
oSystem Pumping Record
Form 4
®EP has provided this form for use=by 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
local Board of Health to determine the forrin they use. The;System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Facility Information
1. System Location; Lift nt of oh us Left/Right rear of house, Left/right side of house, Left
Right side of building, Lent/Right fr6nt of building, Left/Right rear of building, Under deck
Address'
city/Town State Zip code
2. System Owner:
Name'
Address(if different from location)
CitylWown tatr Zip code
L
Telephone Number
aPumping
.
1. bate of Pumpi
ng Date 2. Quantity,Pumped: Gallons
3. Type-of system: ® Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? 0 Yes ® No
5. Condition of Systen?,_..-}�-•�,�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprlses Inc
Company
7. Loca' contents-were disposed:
Lowell Waste Wafer
Signh a Haut Crate
t5fbnn4.docd 06/03 System pumping Record.page 1 of 1