HomeMy WebLinkAboutSeptic Pumping Slip - 42 OLYMPIC LANE 5/8/2012 � J pouoJ�wuuw
EDI.
Commonwealth of Massachusetts
u W C ity/Town of 0
System u pin Record TOWN �d��%�"��ta�U��� �T
Form 4
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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, Leftl jghe - ...
ur, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address M C
k
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record C...._.._
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Location,here contents were disposed:
G.L . Lowell Waste Water
Sign toe I�Haule Date
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