HomeMy WebLinkAboutSeptic Pumping Slip - 32 OLYMPIC LANE 5/24/2016 : 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
I. System Location: Left/Right front of douse LRi re r of hous Leff/right side of house, Left/
Right side of building, Left/Right front of building, Left Ig t rear of building, Under deck
. Address
Cityrrown State Zip Code
2: System Owner.
i
Name
Address(if different from location)
citylrown ' State 1p Code ;
Telephone Number
.13. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons c
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
ther(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 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. Loca' �ere-qpntents-were disposed:
Lowell Waste Water
SignAtute 9t Haulejj Date
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