HomeMy WebLinkAboutSeptic Pumping Slip - 146 OLYMPIC LANE 12/17/2015 1
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Commonwealth Of MassachuS a ,v
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S ystem Pumping-Record
Form 4
10''`� r`'� 4t, ,
DEP has provided this form for use=by local Bo�arcls of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using Ahis 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 house, Le igh rear of h�us�e, Left/right side of house, Left/
Right side of building, Left/Right front of building, eft/Right rear of building, Under deck
Address p � � ��C� LV\
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown ' Stater° , • �p Code ;
Telephone Number 1 7 4
.B. Pumping record ,--
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® o f If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
Vt-
I p ,
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ;w re contents were disposed:
7,.L S:i Lowell Waste Water
Signitufe Haule Date
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