HomeMy WebLinkAboutMiscellaneous - 59 ROCKY BROOK ROAD 4/30/2018 (43) Commonwealth of Massachusetts
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System Pumping Record
Form 4 NOV i t ZQ1Q
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DEP has provided this form for use by local Boards of Health. Othe fgfq e
information must be substantially the same as that provided here. B fo �� 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.
A. Facility Information
1. System Location: Left front of house<oght front of house ft side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
CityfTown State Zip Code
2. System Owner-
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Name
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Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: Galioris
3. Type of system: Cesspool(s) �1V SSe tic Tank
[:1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesNo If es was it cleaned? Yes No
Y
5. Condition of System:
os�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locati here contents were disposed:
G.L.SS. Lowell Waste Water
Signature of Hauler Date
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