HomeMy WebLinkAboutSeptic Pumping Slip - 86 BROOKVIEW DRIVE 4/3/2018 Commonwealth of Massachusefts RECEVn
m; a r ii tIORTO fOIDOVER
Form
®EP has provided this form forrasa-by local Boards of Wealth. 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 forfh they use.Tire Systern Pumping Record roust be submitted to
the local Board of Wealth or other approving authority.
A. acil!ty, InforMation
1, stem Location: Left/Right front of Pious � 1,
Rrght side of building, Lef g/Right front of bui drug,Left/Right r aof house, Left/
u Left/ri
®f building,tdet!�"dma
Cityrrown State Zip Code
2. System Owner: :kl
Name'
Address Of different from location)
Cityrrown ' State Zip Code
c
Telephone Number `
•z d
i
Ppmpling Rpeordt
4. Date of Pumping elate 2. (quantity Pumped: Gallons
3. Type-of system: El cesspool(s) Septic Tank 0 Tight Tank ,•
Other(describe):
4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? Yes ❑ No,
6. Condition of System: in '
6,• System Pumped By:
Nell.Meson F6821
Name Vehicle l'roanse Number
Bateson Enterprises Inc'
Company
7. Locatio re contents-were disposed:
r�S. Lowell Waste Water
. f
sign a —HaulmU Cate
tform4.dov 06/03 System Pumping Record*Page 1 of 9