HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 7 HAY MEADOW ROAD 10/1/2019 : Commonwealth of Massachusetts
City/Town of pC� p 2p19
System Pumping Record HA�p�vEFt
Form 4 N�R,FRTM'ENj
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CEP has provided this form for use-by local Boards of Health. Other forms may used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form 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/Right front of house ft fight r�6fhou , Left/right side of house, LeftRight side of building, Left/Right front of bui trig, Left/ g building, Under deck
Address
City/Town State �J Zip Code
2. System Owner.
Name
Address(ir different from location)
Cilyfrown State LVde
Telephone Number
B. Pumping Record
1. Date of Pumping Date �2. Pumped: Gallons
3. Type of system: ❑ Cesspool(s) k ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? El Yes ❑ No
5. Condition of Sy to :
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. e contents-were disposed:
Z L S Lowell Waste Water
Signitufa cl Haul Date
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