HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 175 OLYMPIC LANE 1/13/2020 RECEIVED
Commonwealth of Massachusetts
. City/Town of JAN 1 3 2020
System Pumping Record TOWN OFHEALT DEPARTMENTOVER
Form 4
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:might tr6nt of house,'Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fro�buildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWTown State Zi Code
Telephone Number
B. Pumping record
1. Date of Pumping Date , C 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [J'Iq;' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System- � ✓�� / t�'�� ,�V t� � ��9�
v
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Haul Date
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