Loading...
HomeMy WebLinkAbout- Septic Pumping Slip - 96 FARNUM STREET 4/3/2019 L (% Commonwealth of MassachusettsCity/Town of w Pumping, cord ; Form 4 � � ����`����� �f��c ®EP has provided this form for use-by local Boards of Health. Other forms maybe used,but the information-must be substantially the same as that provided here. Before using.this form,check with your j local hoard of Health to determine the forrh they use.The$ystern Pumping Record must be submitted to the local Board of Health or other approving authot-ity. l A. FaclOty. inforM tion I. System Location: Left/Right front of house, Left/Right rear of house,( right side of house, Left T6' t side of building, Left/Right fra�nt of building, Left/Right rear cif bulk Wig, Under deck VV\ 5 Ad ess Citylrown State Zip Code 2. System Owner: n, C Name' Address of different from location) Cityf town Stater Zip Code ID Telephone Number t Pumpling Record 1. ©ate of Pumping ` 2. Quantity Pumped: Dat Gallons 3. Type-of system: Cesspool(s) fa Septic Tank ❑ Tight Tank i. ❑ tither(describe): 4.. Effluent Tee Filter present'? ❑ Yes ❑".No if yes, was it cleaned? Yes ❑ No, . Condition f'System: ,����, 6; System Plumped By., Nell.Sateson ' F5821 Name Vehicle License Number Sateson Enterprises Inc' Company 1, 7. Location where contents,were disposed: MLS-D Lowell Waste Water Sign a"HbulKu L1ate j t5form4.doo^08/03 System Pumping Record b Page 1 of 1