HomeMy WebLinkAboutSeptic Pumping Slip - 249 CARLTON LANE 5/18/2016 Commonwealth
_ City/Town of ,m
b System i
Form 4 10 v
DEP has provided this form for use�by local Boards of Health. Other forme 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 house, Left/Righ rear of house 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: 1
Name
Address(if different from location)
cityfrown State ip bode ;
Telephone Number ✓`
B. Pumping Record
1. Date of Pumping ®om 2. Quantity Pumped:
Gallons
3. Type of system: ® Cesspool(s) pti Tank ank ❑ 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.Bateson F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
Sign a I Haul; Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1