HomeMy WebLinkAboutSeptic Pumping Slip - 57 OLYMPIC LANE 11/7/2016 Commonwealth of Massachusetts RECEIVED
= QWTown of JV 15 2016
n.
System Pumping-Record
TOWN OF,NUKIHANDOVtR
r Form 4 HEAurll E ,�R MENT
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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 forrh 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 douse, �0'g rear of ha s?Left/right side oaf house, Left/
Right side of building, Left/Right front of buildh6g, Le ig"�f building, Under deck
Address
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City/Town state Zip Code
2'. System Owner.
Name'
Address(if different from location)
Citylrown ' Stat , ip de
Telephone Number +`
a t
•
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type•of system: ❑ Cesspool(s) ® eptic Tank ❑ Tight Tank .
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep E] If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition o€Syste
6: System Pumped By:
Neil.Batesbn 1=5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio w re contents-were disposed:
V-GL.S'-P Lowell Waste Water
Sign a I Haule Date
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