HomeMy WebLinkAboutSeptic Pumping Slip - 117 BROOKVIEW DRIVE 6/7/2016 Commonwe'alth of Massachusefts RECEIVED
JUN I
T.
YS
q Form i i DU A EO'
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.
Facility. Information.
1 RSystem Location: Left/Right front of house, Left/Right rear of ight side of building, Left R Right front of building, Left/Right reaor of ig nder deck
hou Left/
+
Under deck
Address
CWTown State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown ' State ...� �. Zip Code
Telephone Number
i
. Pumping Kecord
1. Cate of Pumping date 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? Yes
p � •, ® No If yes, was it cleaned? es tj No,
5. Canditian�of tem: �° .
�.
6. System Pumped By: c' �
Neil.Batesan ' F5621
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loccqtio,here contents were disposed:
w
G L S.0 Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1