HomeMy WebLinkAbout- Septic Pumping Slip - 31 JAY ROAD 3/4/2019 Commonwealth of Massachusetts
CityfTown of
PumpingSystem
Form
®EP has provided this form for us&by local Boards of Health. Other forms maybe used, but the
information-must be substantially the tame as than 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 Information
1. system Location: Left i ht frrgnt of hicu , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig 5t ront of building, Left/Right rear of building, Under deck
Address
city/Town state Zip Code
2. System Owner: (�
Pdame'
Address(if different from location)
City/Town state N.,..� r Zip COO
Telephone Number
Pumping Rcor
1, ®ate of Pumping pate 2, Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? es E3 No If yes, was it cleaned? e��No
5. Condition of System:
6. system Pumped 6y:
Hell.Batesbn F6821
Game Vehicle License Number
6ateson Enterprises Inc-
Company
7.iftne
here content were disposed:
Lowell Waste Water
Haule Date
tftrm4.dot,-08103 System pumping Record a page 1 of 1