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HomeMy WebLinkAboutSeptic Pumping Slip - 120 CARLTON LANE 8/8/2016 Commonwealth of Massachusetts City/Town of . RECEIVED y' p` g Record AUG S stem Pum �n ' . F©rm 4 TOWN O :WORT H N�00VUR DEP has provided this form far use=by local Boards of Health. Other fd i;Tffia b6T&s6d, 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: Left/9,front of hour 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 City/Town State zip Code 2. System Owner: Name' Address(if different from location) City/Town ' State Zip Cade ` Telephone Number r .B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type-of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: -p V-A-zz L�� Ge-,C,� VI-0 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises lnc' Company 7. Locatio a contents were disposed: Lowell Waste Water S1gnVtLkfeHauleV bate 06=4.doc•06/03 System Pumping Record«Page 1 of 1