HomeMy WebLinkAboutSeptic Pumping Slip - 19 BEAVER BROOK ROAD 6/13/2017 � ..
Commonwealth of Massachusetts � q A
.Cityffown of t
° Sy tem Pumping-Record 04005
Form 4 �
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 tee
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of Mouseft igh ear of ho:: , Left•/right side of Mouse, Left
`
Right side of building, Left/Right front of b mg, Left/Right rear of building, Under deck
Address
cityrrown / state Zip Cade
2. System Owner: �
Name
Address(if different from location)
cityfrown State, Zip Code ;
Telephone Number 1+ {
r
Purvetping.Record
1. Date of Pumping bate 2. Quantity Pumped:
Gallons
3. T e•of s sterni: s.
Type-of Y ❑ Cesspool(s) Septic Tank ❑ Tight Tank
® Other(describe):
4.. Effluent Tee Filter present? ❑ Yep a if yes, was it cleaned? ❑ Yes ❑ No,
. 6. Condition of s m:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
?. Locatiohere tents-were disposed:
�L S: Lowell Waste Water
r;
Sign t e Hauls Date
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