HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 OLYMPIC LANE 5/18/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record MAY 1 8 2020
Form 4 TOWN OF NUR f H ANUUVER
FiEr,!TH DEPARTMENT
DEP has provided this form for use--by local Boards of Health. Other forms maybe used, but the
information must be substantially the same as that provided here. Before using.this foram,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/ t r of ous -/right side of house, Left
Right side of building, Left/Right front of building, 'ght rear of building, Under deck
Address '-� o C_C:;LA.,,,e --
city/Town State Zip Code
2. System Owner.
Name*
Address(if different torn location)
CWTown State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping ,5 Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.
Neil Bateson F5821
Name Vehicle Ucense Number
Bateson Enterprises Ina
Company
7. Location a contents-were disposed:
G L'an
Lowell Waste Wafer
SignWe Haul Date
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