HomeMy WebLinkAboutSeptic Pumping Slip - 37 OLYMPIC LANE 9/12/2016 Commonwealth of Massachusetts RECEIVED
Citj /Town of
Sy,4tern Pumping.Record igrx::,'H ZrXWER
Form 4 i ffN l-:DEF�A MIEwff
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 submifted to
the local Board of Health or other approving authority.
A. Facility, Information.
1. System Location; Left/Right front of house, Left l- t rear of ho su a,Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ iigi�ar outbuilding, Under deck
Address r
" �. -_
ciitylrown State Zip Code
2. System Owner:
Name*
Address(if different from location)
Citylrown State Zip Code ;
t
Telephone Number .
r
1'
.B. Pumping Record
1. Date of Pumping rate 2. Qua `ty Pumped: Gallons —
3. Type-of systent. ❑ Cesspool(s) El Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of stem.
SY .
r
6. System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
N
Sign a cf Haule [late f
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