HomeMy WebLinkAboutSeptic Pumping Slip - 37 CARLTON LANE 10/28/2016 (2) : X Commonwealth of Massachusetts RECEIVED
CitWTown of .
NOV ?-016
System Pumping.Record
.. Form 4 TOW11�.F G
, HEA:.h)-i DL�'A[6)AEM'
DEP has provided this form for use:by local Boards of Health. other form's maybe'used, but the
information-must be substantially the same as that provided here. Before using.fhis 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/Right front of house, Le tit rear of hoes. , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righ reai oo building, Under deck
Address
_ w
City/Town State - Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown State' Zi
- 4 , e
Telephone Number
ai
.B, Pumping Rpcord
1. Date of Pumping pate 2• Quantity Pumped:
Gallons
3, Type-of system: ❑ Cesspool(s) I a Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E344-6— � If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:n
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location.. hh—q contents were disposed:
G( S Lowell Waste Water
Sign a Haule Date 5
t5forrn4.doc 06/03 System Pumping Record•Page 1 of 9