HomeMy WebLinkAboutSeptic Pumping Slip - 86 BROOKVIEW DRIVE 9/24/2015 Commonwealth of Massachusetts
= City/Town of .
YS tteen 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, a f/RighiTQ of hnuser Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown state Zip Co E C E IV E D
2. System Owner.
SE
Name
w[() ��C.)C° �,df.M�FH
iih. JJb IVME I� �6'E,AH%11..
Address(if different from location)
Cityrrown ' State °®W Zip Code ;
y Telephone Number
B. Pumping JRecord �.
1. Date of Pumping Date 2. Gantity Pumped: Gail
3. Type-of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
C ry . e
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati ere contents were disposed:
G.L S. Lowell Waste Water
'Sjgnitu a Haule Date 1l
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