HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 623 OSGOOD STREET 7/2/2020 RECEIVED
.A\_ Commonwealth of Massachusetts JUL 01 ZOLO
City/Town of
System Pumping Record o
Form 4
CEP has provided this form for us&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 Inform' ation
1. System Location: Le might front of hhouse, Left/Right rear of house, Left/right side of house, Left
Right side of building, Le Right ront of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No 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. Location vGfi-e-re contents-were disposed:
G L S Lowell Waste WaterffaA
j
Sign We q Hibulwu Date
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