HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 OLYMPIC LANE 9/25/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of SEP 2 5 2020
System Pumping Record
Form 4 TOWN OF
DEPARTMEN R
T
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 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 Le 'gh fron�W7—s&ou
ft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rlgng, Left/Right rear of building, Under decfc
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTawn State � Zip e
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantify Pumped: -Fa
Date llons
3. Type-of system: ❑ Cesspool(s) []Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LMO 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 a contents were disposed:
G L S Lowell Waste Water
9 -1 2 -�
Sign ait HliulerU Date
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