HomeMy WebLinkAboutSeptic Pumping Slip - 53 BROOKVIEW DRIVE 7/31/2017V•
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
informationmust be substantially the same as that provided here. Before using .this form, check with your
local Board of Health to determine the forrn 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 house, Left
t side of houseeft /
Right side of building, Left / Right front of building, Left / Right rear of building. Under dec
•
Address
City/Town
2. System Owner:
State Zip Code
Narpe
Address (if different from lo on)
City/Town •
Stat
0,1
Telephone Number
B. Pumping Record
1. Date of Pumping Date
3. Type -of system 0 Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
' 5. Condition of
6: System Pumped By:
Neil. Bateson
• Name
Bateson Enterprises Inc
Company
7. LocatiorrWhere contents were disposed:
Lowell Waste Water
Sian Hattie
2. Quan Pumped:
Z\D
Gallons
eptic Tank 0 Tight Tank
If yes, was it cleaned? E) Yes :3 Na
F5821
Vehicle License Number
Date
15form4.doo. 06/03 System Pumping Record • Page 1 of 1