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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 154 ROCKY BROOK ROAD 8/20/2019 Commonwealth of Massachusetts RECENED City/Town of System Pumping Record wG 20 7-019 Form 4 T©h'N OF NORI AN �•' ,KEALTH DEP has provided this form for use:by local Boards of Health. Other forms may be used, but the information must be substantially the same 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 house, Left/right side of house, Left Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 1 — - R SLI Ctty/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town State Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By.- Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo contents were disposed: Q L S. Lowell Waste Water SignAtufe 4 Haulev Date t5form4.doa 06/03 System Pumping Record•Page 1 of 1