HomeMy WebLinkAboutSeptic Pumping Slip - 93 ROCKY BROOK ROAD 12/12/2017 Commonwealth of Massachusetts
ClWTown o .
System Pumping.Record
Form 4
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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
d
A. Facility Information
i. System LocatiLe g front. #House eftI Right rear of house, LeftI right side of house, Left I
Right side of bud Left 1 Rr ion o buildin Left 1 Right rear of building, Under dec
g g, g g, 9 g, k
cayrrown State Zip Code
2. System Owner.
game'
Address(if different from location)
Citylrown
Telepbone Number +'
3
I!
.13. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of st
U6)
6: System Pumped By:
Neil.Bateson. F5821
Name Vehicle E_icense Number
Bateson Enterprises Inc-
Company
7. Lpagffo—r—iWkere contents,were disposed:
CLS: Lowell Waste Water
' F
Sign a Haul late
t5form4.dov 06!03 System Pumping Record Page 9 of 4