HomeMy WebLinkAboutSeptic Pumping Slip - 50 ROCKY BROOK ROAD 5/22/2018 t• Ewn m
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Form
DEP has provided this form for use-by local boards of Health. ether 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 forrn they use. The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
cfli • InforMation.
1. System Location: Left/Right front laf house, Left I Right rear of mouse, Left/ ` si'da of haus Left 1
Right side of building, left/Right front of building, Left I Right rear of building, un er deo -
Address
Cityrrown stag zip Cade
2. System Owner: I
Noma'
Address Of different from location)
CltyiTawn State c�., �� (p�Cade
y 'telephone Number
B. q B cor
1, hate of Pumping ®ate 2. Quantity Pumped:
Gallons N
r
3. Type-of system: El Cesspool(s) El Septic Tank El Tight Tank t.
Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? E Yes ❑ No,
5. Condition of.System:
6; System Pumped By:
Neil.Bates-or) F6821
Name Vehicle License Dumber
Bateso i..Ehterprises Inc
Company
7, Location re contents-were disposed:
^L Lowell Waste Water
w
F
Sign a Hhul Date
t5form4.doce 06/03 System Pumping Record a Fuge 1 of 1