HomeMy WebLinkAbout- Septic Pumping Slip - 50 BROOKVIEW DRIVE 5/1/2019 i.
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Commonwealth of Massachusefts
elly/Town of
System Pumping Record
Form 4
1
DEP has provided i v
by IccalBoards of,Health., Other fbrmis maybe'used,but the
information- . fi w Before using.thl's ,check
1=61 Board of Health to determine the form' they use.,TheSystern Pumping Record,must be Submitted to
the l l lth or,other approvingu i .
v.
A. Facility InforMatimon,
1. System Location: Righ, qt�o hous Left/R" ht rear of house, Left. right side of house, Left,/
eN 19
Right side of
J
iitbuilding,, Left Ri luildins, Left I Pight rear(if building, Under deck
Address,
C /rows state Zip Code
2, System Owner.
e � I
Nome
�1
J
Address(if d0ifferent from lffo
CitoTown Stat Zip Code
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el ep r
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' ... y �
Record,
M . Pumpling,
qy
Gallons1, Date of Pumping 2. Qui3ntitv Pumped: --------
I
r
3, Type-of� s stern. Cesspool(s) 01--S�eptic�Tank E] Tight Tank
El Other(describe).
Filter,4. Effluent Tee present? Yes o91-0w��If Yes, was it cleaned? 'Yes No
5�. Condition of System:
. Systern Pumped By:
Nell.Bates7on .
Vehicle r
Bateson Ehte[prises Ina
Company
7. Location where content,&were disposed.:
G. Lowell Waste Water ,
a
SlanAwfe ct-Hbul Date
WbuM
. /03 System PumpingRecord