HomeMy WebLinkAboutSeptic Pumping Slip - 107 OLYMPIC LANE 8/23/2017 Commonwealth of Massachusetts
M ,UWTown of .
System Pumping.Record
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 forret they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Faicllity. Information
_ 1
1. System Location. Le Right �0-0�� =ildlfig,
Left/Right rear of house, Left/right side of house, Left/
Right side of bui? eft/RiLeft/Right rear of building, Under deck
Address •C � �` ^� ��� �..� ����'w �''✓t`a,t:,:�;�,./•.., ,t.�.-�.,./
Cityfrown r._. State Zip Code
Z. System Owner.
Mame' J
Address(if different from location)
City/Town � .. State ,-�„�. C�Z'ipd�
Telephone Number r'
Pumpingy record �.
1. Cate of Pumping bate 2. Quantity Dumped: Gallons N
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank i
❑ Other(describe):
d.. Effluent Tee Filter present? ❑ Yes ED_N6'__ If yes, was it cleaned? ❑ Yes ❑ No,
5. Condi `on of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents•were disposed:
jSign
gtMa
Lowell Waste Water
f Date
0orm4.doc°08103 System Pumping Record a Page 9 of 1