HomeMy WebLinkAbout- Septic Pumping Slip - 163 SUMMER STREET 3/4/2019 Commonwe8ilthu
t City/Town of
System Pumping r
Form
®EP has provided this form for use-by local Boards of Health. Other forms maybe*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 forrh they use.The;System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Informiation
1. System Location: Leh/Right front of house, ft ighojg:��r
, Left./right side of house, Left/
de o building, Le /Right front of bull rt Left buildin Under deck
Ftrght sl f 9, � 9 9� 9�
Address
City own State Zip Cone
2. System Owner:
blame'
Address(if different from location)
City/Town Statr r Zi Code
Telephone umber
Pumping ftecr
1. date of Pumping late 2. CWudntih/Pumped: Gallons
3. Type-of system: E] Cesspool(s) eptic Tank 0 Tight Tank
0 Other(describe):
4. Effluent Tee Filter resent?p ® Yes o if yes, was It cleaned? Yes No
5. Condition of Syste .: \�
1
6. System Pumped By:
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. ReHmul
contents-were disposed:
Lowell Waste'Water
Si Date
t5formdt.dood 08/03 System Pumping Record g Page 1 of 1