HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 BROOKVIEW DRIVE 8/4/2021 .� Commonwealth of Massachusetts RECE�v��
City/Town of
System Pumping Record �uG. IHPNDUVEFR
OR
Form 4 TpQfi ta�PRRjMEN,T
DER 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, LeftkRigktrear of house, Left/right side of house, Left
Ri h side of buildijq, Left/ Right front of buildirid, Left I Right rear of building, Under deck
Address
,✓V A47leec4', - �
City/Town state Zip Code
2. Sy>tpm Owner:
. ?w6 _
Name
Address(if different from location)
City/Town State/ ,?/ / ,� e Gode
Telephone Number C�
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:
L
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S. Lowell Waste Water
Signiftie qt Haul Date
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