HomeMy WebLinkAboutSeptic Pumping Slip - 105 BROOKVIEW DRIVE 12/6/2017 : Commonwealth of Massachusetts
CitWTown of .
System Pumping-Record
Foirrn 4
DEP has provided this forrri for use-by local Boards of Health. Other forms maybe'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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
Q. Facility inforri�ation
1. System Location: Left 1 Right front of house, Left rear of , Left/right side of house, Left 1
Right side of building, Left 1 Right front of buildirig, Left 1 Right rear of building, Under deck
Address
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Cit town State - Zip Code
2. System Owner. `
Name
Address(if different from location)
Citylrawn State �7�n C
G�
Telephone Number
1
.B. Pumping Record
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1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? ❑ Ye's Ld'No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
�A_
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Locati w contents-were disposed:
G_ Lowell Waste Water
Sign a i�aufMU
Date
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