HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 BROOKVIEW DRIVE 5/26/2020 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 MAY 2 5 2020
ANDO
DEP has provided this form for use=by local Boards of Health. Other � tJsl ut the
information must be substantially the same as that provided here. Befo' ing. is form,check with your
local Board of Health to determine the forrh 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/ ;t rear_4f house; Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address P7
CWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityf town State e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location contents-were disposed:
Lowell Waste Water
qS�igna Haul Date
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