HomeMy WebLinkAboutSeptic Pumping Slip - 35 BROOKVIEW DRIVE 6/17/2017 Commonwealth of Massachusetts
CiWTown of .
Sy,4fem Pumping-Rekord �� �� �3
Form 4
DEP has provided this form for use-by local Boards of Health. Other firms may be 6i�, but the
Information,must be substantially the same as that provided here. Before using,this form, *
heck 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 Informi ation
1. System Location: Left/Right front of house, Left/ ear of hoes Left/right side of house, Left/
Right side of building, Left/Right Rant of building, Left/Righ rbuiid'mg, Under deck
Address
citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State Ar°� Zip de
f
Telephone Number
. Pumpling Record17
.
1. Date of Pumping gate �Qu6anity Pumped: Gallons3. Type of system: ❑ Cesspoo!(s) nk El Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? M Yes ❑ No,
5. Condition of System:
Aid
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
i
7. Loca` riw contents-were disposed:
L S: Lowell Waste Water
SA
SignVh447HWlevDate f
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