HomeMy WebLinkAboutSeptic Pumping Slip - 44 CARLTON LANE 11/3/2016 Commonwealth of Massachusetts
City/Town of .
Sy'tern Pumping.Record � =
Form 4
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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 Board of Health or other approving authority.
A. Facility. InforMatian
1. System Location: Left/Right front of hou �L"/� lght ar'bf s. Left/right side of house, Left Right side of building, Left/Right front of bLeft/Right rear of building, Under deck
Address
IL
CWTown t ` State Zip Code
2, System Owner. °:'\cc:�,
Name'
Address(if different from location)
City/Town Stat
Telephone Number
.B. Pumping Record
1. pate of Pumping crate 2. Quantity Pumped: Gallons Y
. t
3. Type-of system: ❑ Cesspool(s) �epficTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
U\.4 °'v
6. System Pumped By:
Nell,Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loczbo .' ee contents were disposed:
S: Lowell Waste Water
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Sign tufe I Hi6iiU Date
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