HomeMy WebLinkAbout- Septic Pumping Slip - 427 WINTER STREET 1/29/2019 Commonwealth of Massachusetts
City/Town of
System Pumping r
ff r I t F1" iY
Form 4 HD''
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6
C EP has provided this form for use-by local Boards of-Health. Other forms tray be'used,but the
Information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forth they use. The systern Pumping Record must be submitted to
the local Board of Health or other approving authorlty.
A. Facility Information
_
1. System Location: Left/Fight front of douse, Lett/ �Rrelarh(
I
f hour Leff:/right side of house, Left/
Fight side of building, Left/Right front of building, Leftrear of building, Under deck
Address (-4 2� tl 1 " 0V�
City/Town state Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Stater Code
Telephone Number
13. Pumping r
1. ®ate of Pumping Date 2 Quantity Pumped: i
Gallons
3. Type-of system. Ej Cesspool(s) a— tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes No .. If yes, was it cleaned? ❑ Yes ❑ No
6. Condition of System:
6. System Pumped 6y:
Neil.6ateson F6821
Name Vehicle License Number
Eateson Enterprises Inc
Company
7. Locatic contents-were disposed:
L S. Lowell Waste Water
Sign a F#a ul Date
t formd.do(.-06103 system Pumping Record m Page 1 of 1