HomeMy WebLinkAboutSeptic Pumping Slip - 37 CARLTON LANE 10/28/2016 L Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping-Record NOV 1 15 ai l
Form 4 'TOWN OF NOUH ANM/ER
HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may 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 forum 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 I Right front of house, left/Right rear of hous. e T ig side of hour Left/
Right side of building, Left/Riglit front of building, Left/Right rear of building, Under ec
Address
City/Town state Zip Code
2. System Owner. 1��
Name` 6
Address(if different from location)
City/Town .. Stag � ��, Zi Code ;
Telephone Number
.B. Pumping tlpcord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system. ❑ Cesspooi(s) [0—sepi k ❑ Tight Tank ,
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of System: J
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatio here contents were disposed:
G L S:�) Lowell Waste Water
S Hguler Date
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