HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 206 OLYMPIC LANE 10/12/2021 us RECEIVED
Commonwealth of Massaoh efts ,
City/Town of
> �RTH A�pCVER
System Pumping Record o�jHo��zMENj
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 forrim they use.The.System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Leh/Right front of house, Left/Right redo house,j:eft/right side of house, Left/
Right side of building, Left/Right front of building, Left%Right rear of building, Under deck
Address �
cKyrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Ci Zip own Statt� ������ Code
Telephone Number
.B. Pumping Record /
1. Date of Pumping �—� � tyPumped: r �G�
Date Quahti Gallons
3. Type-of system: ❑ Cesspool(s) ❑ -Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q-tQo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:�kjC
6. Syster,>7 Pumped By:
F5821
i -
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
G-6s.21A 12 Lowell Waste Water
tig—nNure q Auteir Date
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