HomeMy WebLinkAboutSeptic Pumping Slip - 182 OLYMPIC LANE 12/18/2015 l
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Common wealth of Massachusetts
City/Town of
i
Y* to Pumping.Record
Form 4
DEP has provided this form for useeby 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 i ht front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig Wont of building, Left/Right rear of building, Under deck
Address
Ctlylrown state Zip Code
2. System Owner:
Name'
Address(if different from location)
city/Town ' State Zip Code
C
Telephone Number
B. Pumping Rpacord
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neil.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location' 1 re contents were disposed:
U'L S Lowell Waste Water
Sign a Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1