HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 FARNUM STREET 3/2/2020 Commonwealth of Massachusetts RECEIVED
= City/Town of
System P-umping Record MAR G ',1 2020
Form 4 ,ANuuvE^
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CEP has provided this form for us&by local Boards of Health. Other forms may be 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, Left/Right rear of house,((eft-i;�ghtCideh ou Left/
Right side of building, Left/Right front of building, Left/Ri ht rear of buildin , Un
9 9
Address
Cityfrown State Zip Code
2 Systam Owner.
Name
Address(if different from location)
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes rcTNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. where contents were disposed:
G L$S. Lowell Waste Water ^ '
J
Sign aul Date
15form4.docr 06/03 System Pumping Record•Page 1 of 1
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