HomeMy WebLinkAboutSeptic Pumping Slip - 189 CARLTON LANE 7/19/2016 N Common
wealth
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DEP has provided this form for use:by local Boards of Health. Other form 'fie ed,`b Ft the
information must be substantially the same as that provided here. Before usin .this f rrtt neck with your
local Board of Health to determine the form they use.The System Pumping Record rf — omitted to
the local Board of Health or other approving authority.
A. Facility. Inf®r tic
1. System Location: ?�
ru� phs�
�,)Left/Right rear of house, Leff/right side®f house, Left
Right side of building, Left/Rig� front /
of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. ,
A �
Name'
Address(if different from location)
CityfTown ' State - t Zip Code
Telephone Number
Pumping Record �.
1. Date of Pumping Date 2. Quantity Pumped:
. -� Gallons
3. Type-of system': ❑ Cesspool(s) (l"'Septic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of.System: j
6: System Pumped By:
Neil Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location whe
re contents were disposed:
G _m , Lowell Waste Water
Sign a Haute Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1