HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 186 BRADFORD STREET 5/17/2021 :�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
CEP has provided this form for use-.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 hou�g rear f house, Left/right side of house, Left 1
Right side of building, Left/Right front of b ' ing, Left/ uilding, Under deck
AddressG�1cuIL -
cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
�v3
Telephone Number o
B. Pumping record
aj fO
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? ❑ Yes 0-1 o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca
' e contents-were disposed:
G.L S Lowell Waste Water
L-RISA.
-7- �G C
Sign a HIaut w U Date
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