HomeMy WebLinkAbout- Septic Pumping Slip - 1620 TURNPIKE STREET 1/29/2019 Commonwealthf Massachusetts
City/Town of
System Pumping Record
h Form 4
CEP has provided this fora for use-by local Boards of Health. Other forms may be bsed, but the
information-must be substantially the game 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 t®
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Leff/Right front of building, Left/Right rear of building, Under duck
Address
cityrrown State lip coin
2. System Owner: �
Name
Address(if different from location)
City/l"own State ZIPcads
'telephone Number
Pumpingcoy
1. bate of Pumping Date 2. Quaintity Pumped:
Gallons
3. Type-of system: ® Cessooi(s) is Tank 0 Tight Tank
tl'i�r(describe):
4. Effluent Tee Filter present? ® Yes ® No if yes, was it cleaned? ❑ Yes ® No
5. Condition of Syste ,.
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License dumber
Batesori Ehte rises Ina
Company
7. Locati contents,were disposed:
G L S. Lowell Waste Water
Sign WHOul Mu
Cate
t5form4l.doc•06/03 System Pumping Record g page 1 of 1