HomeMy WebLinkAboutSeptic Pumping Slip - 101 ROCKY BROOK ROAD 8/23/2017 Commonwelalth of Massachusefts
RECEIVED
C4/Town o .
Sry,4tem P-umpin§.Record ��.���� �� � � ..��
x - Form 4
TOWN OF I40M��
H�
°fH DEPAR
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 forrn they use. The System Pumping Record must be submitted to
the local.Board of Health or other approving authority.
A. Facil%ty Information
I. System locatio . L igh Nous Left/Right rear of house, Left/right side of house, Leff/
Right side of bui mg, Left/Right front of Left/Right rear of building, Under deck
Addressc
l G� ., /2)
City/Town State Zip Code
2. System Owner.
DO.
Name'
1
Address(if different from location)
City/7 own StateG _4 ),r� e
C
t Telephone Number
. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ®-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ® Yes ❑ No,
5. Condition of stem: fI
6. System Pumped By:
Nell.Bateson - F6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca' 1e contents-were disposed: J
CL S. J Lowell Waste Water
F
WeHiaule Date
tS=4.dov 06/03 System Pumping Record•Page 9 of 1