HomeMy WebLinkAboutSeptic Pumping Slip - 151 CARLTON LANE 8/16/2016 : Commonwealth of Massachusetts
City/Town of . 11ECXIVED
System Pumping-Record
Form 4 �.,d.,°i
DEP has provided this form for usekby local Boards of Health. Other forms mar �.t,! cdi bUt 4h'e`'C
information,must be substantially the same as that provided here. Before using. is 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: Le eight front of ho�, Left 1 Right rear of house, Left/right side of house, Left/
Right side of building�Wl�ig . ront of building, Left/Right rear of building, Under deck
Address/
µ
City/Town State Zip Code
2. System t7WneC
C_�,
Name'
Address(if different from location)
City/Town • State-
Telephone Number
i
.B. Pumping Record
1. Date of Pumping Date 2. Quanity Pumped: '
Gallons —�
3. Type-of system: ❑ Cesspool(s) ❑ Tank ❑ Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes ® o if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: Q
x
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tic► 'wherA contents were disposed:
L Lowell Waste Water
"ShgnAqe I Haule Date
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