HomeMy WebLinkAbout- Septic Pumping Slip - 84 BRUIN HILL ROAD 1/7/2019 Commonwealth of Massachusetts
UCity/Town of
System Pumping Record
Form 4 �EN �11 DL.FAf,'l MUIT
1
DEP has provided this form for use=by local Boards of Health. Other forms maybe*used, but the
Information-must be substantially the tame as that provided here. Before using.this form,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.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of hous-q /Aht-s��qouse Left I ar
Right side of building, Left I Right front of buildifig, Left/Right rear of bdiding. Unaer
Address
cityrrown State zip Code
2. System Owner
Name,
Address(if different from location)
cityfrown State- do
��
Telephone Number
13. Pumping Record
1. Date of Pumping Date 2. Quitntity Pumped: Gallons
3. Type-of system: El Cesspool(s) D-Sbpfic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned? EJ Yes El No
5. Condition of System:(\JO
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc"
Company
7. Location where contents.were disposed:
G, a. Lowell Waste Water
( ,4
48jigne ' Hhule V Date
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