HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 107 OLYMPIC LANE 10/1/2019 __ Commonweaith of Massachusetts �"^
City/Town of
System Pumping Record
FQITt'1 4 OF
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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 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: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address c� a gZl:�
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from kxmnon)
CitylTown 5ta*—
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qu' tity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M40 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: �(
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
C�.L S. Lowell Waste Water
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Sign a Heul D�
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