HomeMy WebLinkAboutSeptic Pumping Slip - 79 ROCKY BROOK ROAD 5/17/2016 _ Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
Form 4
DEP 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 Location: Left/Right front of house, Left/Right rear of houserig side of hou Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
• Address � �.•� �������'�
City/Town State Zip Code
2. System Owner.
Name* o
Address(if different from location)
CitylTown State/1 ,L C!,e
j �,7
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons r
3. Type-of s stem: ❑ Cesspool(s) [3-IS p tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of StysteLm
6: System Pumped By:
Neil-Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
_L Lowell Waste Water
SignAqe 9f HaulerU Date
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