HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 CHRISTIAN WAY 10/1/2019 Commonwealth of Massachusetts
City/Town of OCR
System Pumping Record ,t,No�No
Form 4 tQ kN
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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�e /Righront of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front oTbuilding, Left/Right rear of building, Under deck
Address
CWrown State Zip Code
2. System Owner.
Name c
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date ` uantity Pumped: --
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L . Lowell Waste Water
Signitufe cfl-laulwU Date
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