HomeMy WebLinkAboutSeptic Pumping Slip - 206 OLYMPIC LANE 1/30/2018 Commonweialth of Massachusefts
6
wn of
2111
syioem Pump Ing.Record
C i ltiii 1 'V .F
FormM OFl
DEP has provided this farm for use-by local Boards of H lth. Other farms 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 forth they use.The,System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FactlitlY. Information
1. System Location: Left/Right(rant of Mouse, Left tgh"t rear of hc , Left/right side of house, Left/
� Right side of building, Left/Right front of building, Le lght rear of building, Under deck
Address /'
Cityfrown State Zip Code
2. System Owner
�f`�L
Name'
Address(if different from location)
CityfrownStag Zip Code
t
" � •.
Telephone Number h w
i
.B. PuMpIng
r
1. bate of Pumping crate 2. Quantity Pumped: Gallons "
3. TypeW system: ❑ Cesspool(s) aseoiic Tank 0 Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes -°iso". if yes, was it cleaned? E Yes El Inc,
5. Condition of Syste
6.. System Pumped By:
Neil.Meson F5521
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tiwh re contents,were disposed:
•8. Lowell Waste Water
I,
Sign a Haule Cate
tMrrrm4.doc-06/03 System Pumping Record d Page 1 of 1