HomeMy WebLinkAbout- Septic Pumping Slip - 105 BROOKVIEW DRIVE 6/13/2019 I'll
GRY/Town of
R /Commonwealth of Massachuseffs mt
System Pumping Record
m
91
Form 4
(11 w
l
DEP has provided this form s w l Board's � then may b ' �,but the
inform: gin,m a s s � fi ll the s row here. r i .this fog,check with your
local Board of Health determine the for. they use The eats ecord must be submitted to
the local, Board of Health or other approving
A. Facility InforMation
A.
. System Right front pf housd:;i,,, l , r a eft.�"right sidehouse, Left I
Rightside f building, fight build o rear buy"Ids , ' nde �
Address
k.A
µ.me
cityfrow
n State Zip code
System
Address Of differentfrom location)
I stater
.. r
phone Number
1,000
.B. Pum ping Record
I., Date of Pumping Quiinfi Pumped: Gallons,
I Type-of system: E] iI Tank
0 Other(describe),"
Filter Present? El Yes C,30 01 If Yes, was it cleaned? Ej Yes, 0 No
l
r
j
V�-
6. Systern
Nell.Batesbq W tF5821,
Name Vehicle
Bateson . !qmrises I
Company
w
sposeas-
w JP? —Lowe—IlWaste Water
..........
signX a Houl Date
. Pumping