HomeMy WebLinkAboutSeptic Pumping Slip - 95 OLYMPIC LANE 12/2/2015 i
Cony mon wealth of Massachusetts
City/Town of . 1
yitem pin rd
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: Left/Right front of hous%1!D ear of h s Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address r
City/Town State Zip Code
2. System Owner:
,a
Name ,q
Address(if different from location)
Cityfrown ' State Zip Code
Telephone Number a J,
i
B. Pumping Record .
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type-of system,- ❑ Cesspool(s) [3--septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location ey wh contents were disposed:
G L S: Lowell Waste Water
W
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1