HomeMy WebLinkAboutSeptic Pumping Slip - 129 CARLTON LANE 5/26/2016 Commonwealth of Massachusetts
= City/Town of .
System 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. System Location: Left/Right front of house, Left/Right 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
Zit Tr own State Zip Code
2. System Owner:
Name'
Address(if different from location)
city/rown State Zip Code ;
Telephone Number 4
• 3
.B. Pumping JRecord y�..
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 L If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System, r
Lave
6. System Pumped By: w
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7: Location where contents were disposed:
.L Lowell Waste Water
Sign a I HaulsV Date
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