HomeMy WebLinkAbout- Septic Pumping Slip - 53 CEDAR LANE 1/29/2019 Commonwealth of Massachusetts
City/Town of "J,
System u p ireRecord
Form 4
®EP has provided this form for use-by local Swards of Health. Other forms may be'used, but:the
information-must be substantially the tame as that provided here. Before using.this form,check with your
loam Board of Health to determine the forth they use.The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
1. System Location: Left/bight front of Mouse, Left/Right rear of house, Leff/right side of house, Left
Plight side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
!) -:� e-e_(�, —
CiRrown Mate Zip Code
. System Owner:
Name'
Address(if different from location)
Cityfrown State-..--., Zi Cade
Telephone Number
.B. Pumping Record
1. ®ate of Pumping Data 2. Qu'ntity Pumped: Canons
3. Type of system: Cesspoo!(s) Septic Tank Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present? (l Yes o if yes, was it Cleaned? ❑ Yes ® No
5. Condition of System:
6, System Pumped By:
Nell.Satesion F6821
Name Vehicle license Number
Sateson Enterprises Inc
Company
7. Loca "o contents,were disposed:
C L^ Lowell Waste Water
C
Sign a Houle Crate
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