HomeMy WebLinkAboutSeptic Pumping Slip - 213 CARLTON LANE 6/16/2015 Common
wealth of Massachusetts
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item Pumping.Record
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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 !A,., Right roi of ho,-j , 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
..A
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State Zip Code
\0A fele hone Number ;
B. Pt;mping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons
3. Type of system-. ® Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No,
" 5. Condition of System:
6: System Pumped By:
Neil.Bateson F5621
Name Vehicle License Number
Bateson Ehtemrises Inc'
Company
7. Location where contents were disposed:
*eH'aule Lowell Waste Water
IS..
Sign t Date
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