HomeMy WebLinkAboutSeptic Pumping Slip - 95 OLYMPIC LANE 6/8/2016 <C\ Commonwealth of Massachusetts
City/Town of
a
System Pumping a r�ry 2(,3 ����lt!
c� Farm 4 7 CpN"µ'ppu"1µORTiytqq �6�i�°�C�VER
DEP has provided this form for use by local Boards of Health. Othe rr❑"brtr§-6-d e
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 side of house, Right side of house, Left front of house, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address , p
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City(rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
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:
e
QeA)
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc__
Company
7. Loc }Qqo h \contents were disposed:
.L �.D-' Lowell Waste Water
6 s
g to a of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
-
City/Town of
Y System Pumping ri,i �iryrri�
Fora 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 t4 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 Laoatiofl, Left side of house, Right side of house, Left front of house, Right front of house,
eft rea-r
eft.. ofiaus�Right rear of house. Left rear of building. Right rear of building.
Address
�.
------ - -- ---- ------- ----- ---- --
� f .,fit/� r
-- - ��-------
Cityrrown State - — Zip Code ----
2. System Owner:
Ue"Ar
Name -- -- -
Address(if different from location)
--- -------
----- ----------
City/Town – Skat – Zi Code
Telephone Number
B. Pumping ecor
1. Date of Pumping Date -. - — Quantity Pumped: II`"
Ga ons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): -- - - ---
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. ConditionAofnS��t �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S. Lowell Waste Water
-- --- ------
Signature of Hauler Date
t5form4.doc^06/03 System Pumping Record a Page 1 of 1