HomeMy WebLinkAboutSeptic Pumping Slip - 83 OLYMPIC LANE 12/17/2015 Common wealth of Massachusetts
City/Town of
YS tem Pumping.Record
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 Right side of building, Left/Righter =fsbuild'° eft/Right rear of.house, Left/right side of house, Left/
h#front
oing, Left/Right rear of building, Under deck
Address n
City/rown State Zip Code
2. System Owner.
Name*
Address(if different from location)
citylrown ' State Zi Code ;
Telephone Number 4
1
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons
3. T yp e-of system. Cesspool(s)ool s e tp ic T a
nk El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
C L Lowell Waste Water
<��5-hMSA t 4, �3......
-Sigdhje qf Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1