HomeMy WebLinkAboutSeptic Pumping Slip - 41 BEAVER BROOK ROAD 11/17/2015 : Commonwealth of Massachusetts
City/Town of .
System 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, Left/Right rear of hous. , Le •/ side of ho seu eft/
Right side of building, Left/Right front of building, Left/Right rear of bul ding, Under deck
Address —(e:
e—c— bx CWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown St @.te Zip.Qode
Teleph ne Number
B. Pumping JRecord �
1. Date of Pumping Date �2. ua nti Pumped. Gallons
3. Type-of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lam'No If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio whe contents were disposed:
L S. Lowell Waste Water
�C -'j
F
S1qnjqe cf HAulejj Date
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