HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 694 FOREST STREET 5/18/2020 Commonwealth of Massachusetts
City/Town of
4. System Pumping Record
Form 4
CEP has provided this form for usez by local Boards of Health.Other forms may beused,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, t r of ho . , Left/right side of house, Left
Right side of building, Left/Right front of buil ind' �g, Left/ Mg- rear of building. Under deck
Addresso:?
Citylrom State 0� Zip Code
2. System Owner.
Name"
Address(W different from location)
CWawn State
Telephone Number G j'
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of 7n>_ V_
t
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a contents-were disposed:
G L Lowell Waste Water
Sign a Haul Date
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