HomeMy WebLinkAboutSeptic Pumping Slip - 154 ROCKY BROOK ROAD 6/6/2018 VED
Commonwealth u �n�
Cjt�/Town of
Al
osystem Pumping,Record TOWN 0�:
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I AN
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®EF has provided this form for use-by local Boards®f W lth. Other forma may be'used, but the
information-must be substantially the tame as that provided here. Before using.this farm,cheek with your
local Board of Wealth to determine the foiri i they use. The System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. cl . r ti
1. System Location:Right side of building, Leftg/hRirht front of buildLeft/ �t�ofhousLeft/right side pf house, Leig g, g, uilding, Under deck
Address
City/Town State Zip Code
2.. System Owner:
tN'l "✓lt•��5 ••
Address Of different from location)
Cityrrown ` State• Zip Cods
`etephone Plumber
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®®pp® .
eord O I m 4d .. j
1. bate of Pumping C,- Z,6,- 1 ,9 uantity Pumped:
Date Gallons r
3. Type-of system: [l Cesspool(s) Septic Tank ® Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? Yes No If yes,was it cleaned? ® Yes ® No,
' 6. Condition of.System:
l&I •('
6. System Pumped By:
Alen.Bates ri F5821
Name Vehicle License Number
Bateson �rlterprises lnc•
Company
7. Location where contenterwere disposed:
LS.LSQ Lowell Waste Water
Sign a Haus Cate f
15fotW.doc•06/03 System Pumping Record a Page 1 of 1