HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 BROOKVIEW DRIVE 10/16/2019 : Commonwealth of Massachusetts
City/Town of
.° System Pumping Record
Form 4
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, Lefttf Right rear of fig-eft-/right side of house, Left 1
Right side of building, Left/Right front of building, e /fit Right rear of building, Under deck
Address
LA_ a v
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6d ` 2, Quantity Pumped:
Date 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. Lopoon where contents-were disposed:
G L S Lowell Waste Water
0 - J
4&ignift)fecf Haut Date
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