HomeMy WebLinkAbout- Septic Pumping Slip - 75 HAY MEADOW ROAD 1/29/2019 Commonwealth f Massachusetts
w CifylTown of
System 1
To% I`l l Vf
Form
C EP has provided this form for use>by local Boards of Health. Other forms may be'used, but the
information,roust be substantially the same as that provided here. Before usin .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 InforMation
1. System Locatlon: igh rpn ouse Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig a uiidirig, Left/Right rear of building, Under deck
Address
Cityrrown state Zip Code
2. system owner°.
Name'
Address Of different from location)
Cityfrown stater Zip de
`telephone Number
Pumping Record
1. Date of Pumping Date 2. Quantity pumped:
Gallons
3. Type-of system: Cesspool(s) EmpiricTank Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes 91, o if yes, was it cleaned? ® Yes El No
5. Condition of system:
6. System Pumped 6y:
Nell.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc'
Company
7. 7Locavo here content&were disposed:
L Lowell Waste Water
Signitufe cif HiauleV Cate
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