HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 487 WINTER STREET 1/14/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record JAN 4 7071
Form 4
CEP has provided this form for use-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 Locationd; t` R1ghkff&ni of ft*�U*—S )LeftI Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig ron of building, Left/Right rear of building, Under deck
Address
Mylrown 1 State Zip Code
2. System Owner f r
Name" 1�t
Address(if different from location)
CitylTown State Zip Code
4
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 9-fe� ❑ No If yes, was it cleaned? C3-Ye'sF-] No
5. Conditio Systgm:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle t_Foense Number
Bateson Enterprises Inc
Company
7. Locatio contents,were disposed:
L S Lowell Waste Water
Sign aflitkulerU Date
t5fbrm4.doc•06/03 System Pumping Record•Page 1 of 1