HomeMy WebLinkAbout- Septic Pumping Slip - 41 BEAVER BROOK ROAD 9/24/2018 Commonwealth alth of Massachusetts
CitY/Town of
SY.4tem Pumping.Record
Form 4
M •
DEP has provided this form*for use-by local Boards af,Wealth. Other forms may be'used,but the
information'must be substantially the tame as that provided here. Before using,this form,check with your
local Board of Wealth to determine the form they use.The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority. t
A. Facility, Inf®rr'sition
1. System Location: Left/Right front of house, Left 1 Right rear of house ?e �I ri h side of hour ; Left I
Right side of building, Left/Right front of building, Left/Right rear of bri', under c
Address
City/town State Zip Code
2. System Owner:
Name'
Address(W different from location)
Citylrown ' Stet Zip
p Telephone Number r
Pumping C r (I .
1. hate of Pumping 2. Ouanfi Pumped: ns '�
. Date � p Gallons
3. Type-of system: El Cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? [ Yak O-Ko If yes, was It cleaned? E3 Yes ® No, J
5. Condition of System:
m
6: System Pumped By:
Nell.Bateson F5621
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. LQ pn"h& contents,were disposed:
ISIgne
*Hiiul
Lowell Waste Dater
�.�..
f
Date
15form4.doc-06/03 System Pumping Record m Page 1 of 1