HomeMy WebLinkAboutSeptic Pumping Slip - 105 CARLTON LANE 5/31/2016 Commonwealth u
i t Oyu of ���,u
YS
i n§. Record 1
Firm 4
y �Yt �pl1��y'�pvWr�
u V ti G 81 4�C "�c i:;iMryG VW 41u4"R 4
DEP has provided this form for use�by local Boards of Health. Other forms may be dyad, bu4 the
information must be substantially the same as that provided here. Before using.this form, check with your
Ioc6l 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.
Facility. Inor Lion
1. System Location: Left/Right front of house Le /Right ear"o ouse a Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address - .-
CiWown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown Stated Zip Godj
Telephone Number i
. Ppmping Rpcord -
1. Date of Pumping 2. Quantity Pumped:
Date .�- Gallons r Y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes,was it cleaned? ❑ Yes ❑ No,
' S. Condition of Syste .: •6alt
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tion�utreT contents were disposed:
G L S: Lowell Waste Water
Sign a Haule Date
t5form4.dow 08/03 System Pumping Record•Page 1 of 1