HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 ROCKY BROOK ROAD 5/17/2021 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record MAY 17 ZVI
Form 4 Tn,,0A nF N OF
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 Locatio �gft, Liefl
g runt of house,j.eft/Right rear of house, Left/right side of house, Left
Right side of bu , /Rightf6V ofYWIding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown Stag jpc.,Qge
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) D--Se—pt&Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ej NoT If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systerp:
c_
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo here contents-were disposed:
G L S. Lowell Waste Water
Signitule 9t HaulwU Date
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