HomeMy WebLinkAboutSeptic Pumping Slip - 73 CARLTON LANE 8/4/2016 ' Commonwealth .of Massachusetts
City/Town of .
system Pumping-Record
Form 4
bEP ha'i provided this form'*use-by local Boards of Health. other form's 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 br otter approving authority.
A. Facllity. Inform' ation
I. System Location: Left 1 Right front of house, Left 1 lit rear of hous eft/right side.of house, Left I
Right side of building, Left/Right front of buildirig, Left/Right rear of building, Under deck
Address
CitylTown ('� L State - Zip Code
2'. System Owner.
Name
Address(d different from location)
city/Town ' State _(s tip Code
o
Telephone Number t.
s f..
.B. Pumping record
1. Date of Pumping 2. Quantity Pumped:
Date 2.
3. Type-of system: ❑ Cesspool(s) 3--Septic Tank ❑ Tight Tank `
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of.System. �JCK V�
6: System Pumped By:
Nell.Sateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location where contents-were disposed,
UeHgule Lowell Waste Water r,�Date `
5form4.doe-06103 System Pumping Record•page t of 4