HomeMy WebLinkAboutSeptic Pumping Slip - 136 ROCKY BROOK ROAD 4/24/2018 Commonwe'alth of Massachusefts
wUtYffown of
uSyMem Pumping. r �J
a
Form 4
DEP has provided this forryi for use.by local Boards of Health. Other fords maybe`used, but the
information-must be substantially the same as that provided here. Before using.this fora,check with your
lord 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.
A. Facility.
1. System Location: eel!", ig kc f Ficus , Left I Right rear of house, Left/right side of house, Left
Right side of buiC , Left/T ig rant of building, Left/Right rear of building, Under deck
Address
city/Town State Zip Cade
2. System Owner:
Name'
Address Of different from locatlon)
City/Town ` St Z de
f Telephone Number r `t
i
1. ®ate of PumpingDate2. Quantity Pumped: Gallons b
3. Type-of system: El Cesspool(s) eptic Tank D Tight Tank i
Other(describe):
4. Effluent Tee Filter present? El Yes ® If yes, was it cleaned? ® Yes ® No
6. Condition of.System: C
6: System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo tion: ere contents,were disposed:
MLSQ6 Lowell Waste Water
d
Sign a it Flbate
ftnn4.doc^08/03 System Pumping Record•Page 9 of 1