HomeMy WebLinkAboutSeptic Pumping Slip - 19 BEAVER BROOK ROAD 7/19/2017 Commonwealth of Massachusetts
City/Town of ;, �
System Pumping-Record
Farm 4
� DEP has provided this form for use=b local Boards of Health. other forms may
be'used, but t�
- p y y he
information must be substantially the same as that provided here. Before using.this foram, 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 e /Right j- of house;Left/right side of house, Left/
Right side of building, Left/Right front of burg, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
WAS,-
Name'
Address(if different from location)
City/Town State C Zip Code
'o
..�. '
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank F1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Z340 If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition o Sy tem:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo #i re contents were disposed:
CLS-S: Lowell Waste Water
�jctI (S f
Sign a Haute Date
t5form4.doe-06/03 System Pumping Record•Page 1 of 1