HomeMy WebLinkAbout- Septic Pumping Slip - 100 BROOKVIEW DRIVE 4/3/2019 Commonwealth of Massachusetts
Y
City/Town of
System Pumping Record
Form 4
6
0,E�
®EP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information-roust be substantially the same as that provided here. Before using.this form,c*heck 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: Rig f, ton ►f iiou , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rlg ron o uiidirig, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/rown State- �, C Zip Cade
7
'telephone Number
13. Pumping Record
1. date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: Cesspool(s) ptic'Tank [] Tight Tank
Other(describe):
4. Effluent Tee Filter present? [j Yes if yes, was it cleaned? [ Yes ® No
5. Condition of System: 7
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehte rises Ina
Company
T.T^ ere contentewere disposed:
Lowell Waste Water
Cate
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