HomeMy WebLinkAboutSeptic Pumping Slip - 73 CARLTON LANE 8/4/2016 (2) Commonwealth of Massachusetts RECEIVED
City/Town of ;
�E
System Pumping-Record N-<
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 Hoard of Health or other approving authority.
A. Facility. Information
1. System Location: Leff l Right front of house, Leff/faihi rear of hous eft/right side of house, Leff
Right side of building, Left 1 Right front of buildicig, Left 1 Right rear of building, tinder deck
• Address •� � �,��'�� ��� �\. I ��`��� ��.aw��, '
Cityrrown State - Zip Code
2. System Owner: 1j\ 1c �\
Name'
Address(if different from location)
City/Town State 0 f d y Ji de
"telephone Number
.B. Pumping Pacord
1. Date of Pumping to 2. Quantity Pumped:
Gallons
.3. Type-of system: ❑ Cesspool(s) epic Tank ❑ Tight Tank s.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ Na
' 5. Conditlon of System:
ids� ���•� ��.�
6: System Pumped By:
Neil.Bateson • F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
C t S Lowell Waste Water f
_sign a Houle Date
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