HomeMy WebLinkAboutSeptic Pumping Slip - 79 ROCKY BROOK ROAD 7/23/2018 Commonwealth ®f Massachusefts R E C rc:, rDlp
s W I own of
3 2016nsrkem Pumping.Record
ani OF M�XRUHAWOVER
®EP has provided this form for use-by local Boards of Health. Other farms maybe used,but the
information,must be substantially the tame as that provided here. Before using.this ford,check 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.
1. System Location: Left/Right front of house, Left/Right rear of house,se J right Ide"of housLeft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address 4°� �--, (-�,,.��('', . �" � �.,-.'�'. •,�-�'\ �'�... _.._ .�c.,�.�*.,..
Cityi own �, „� State Zip Code
2'. System Owner:
• Name'
Address(if different from location)
Cityfrown stat _Zip Code
P �` .
'telephone Number '
PpmPling Record
1. Gate of Pumping Bate 2. Quantity Dumped: Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank t
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes,was it cleaned? ❑ Yes ® No.
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
company
7. Locati""t ere content.%were disposed:
�L S Lowell Waste Water
;SjgnXHqau1e Cate
MrM .doo-06103 System Pumping Record-Page 1 of 1
