HomeMy WebLinkAboutSeptic Pumping Slip - 79 BROOKVIEW DRIVE 12/4/2017 Commonwealth of Massachuse t
.CIWTown of .
w° sytem P'eump llpg-Record
Form 4 ��.
DEP has provided this form foar use- by local Boards of-Health. Other form's may�be'used, but the
information must be substantially the name as that provided here. Before using.this form,check with your
focal 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 InfQrmi aticm
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of buildidg, Left/Right rear of building, Under deck
Address
f v of
CFWTown State zip Code
2. System Owner:
Name'
t
t
Address(if different from location) i
cityrrown ' State• p qqde 1
fi Telephone Plumber
. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
i
3. Type-of system: ® cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? El Yes a If yes, was it cleaned? ❑ Yes ❑ No,
5. condition of Syste
6. System Pumped By: t
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio Frere contents-were disposed:
Lowell Waste Water 1
. i
SignAtute 4 Haule Date
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