HomeMy WebLinkAboutSeptic Pumping Slip - 7 OLYMPIC LANE 6/25/2014 Commonwealth f Massachusett
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y t Pumping Record
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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' e nd Rigf�"rear of hots , Left/right side of house, Left/
Right side of building, Left/Right front of build rig, Left/Right rear of building, Under deck
Address
Cityfrown 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) ❑•deptic Tank ❑ Tight Tank
[:Ej i r(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: f
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatoonr .where contents were disposed:
G.L S: Lowell Waste Water
SignAtufe 9t HaulerU Date
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