HomeMy WebLinkAboutSeptic Pumping Slip - 59 ROCKY BROOK ROAD 11/17/2015 Commonwealth of Massachusetts l
City/Town of
y' tem Pumping. cord
Farm 4
DEP has provided this fiorm 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: Le Wight frq�of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building1,eel Right front of building, Left/Right rear of building, Under deck
Address
cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
citylrown Stat Z e
Telephone Number
B. Pumping Record "LS, �.
(,
1. Date of Pumping 2. Qyantity Pumped:
Date Gallons N
�.,
3. Type�of system: ❑ Cesspool(s) ❑°Septic Tank ❑ Tight Tank
❑ Other(describe):
. „gym
4. Effluent Tee Filter present? ❑ Yes ❑°'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�M
• .,mom....
6; System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc-
Company
7. Loca' ere contents were disposed:
G L S'. Lowell Waste Water
Signitufe 9t Haule Date
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