HomeMy WebLinkAboutSeptic Pumping Slip - 184 CARLTON LANE 11/11/2016 : Commonwealth of Massachusetts
RECEIVED
r City/Town of .
System Pumping.Record NOV .I F
Form 4
TOWN ile
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 InforMation
1. System Location: Left/Right front of hious , Le ' Righ ear of hous Left/right side of house, Left l
Right side of building, Left/Right front of b��tld'tt�Left/Rig t rear of building, Under deck
g g,
Address
L -(� ,.
Cityfrown State Zip Code
2. System Owner.
Name`
Address(if different from location)
City/T'own • State (� 1p Cade
t ,
Telephone Number
• b . r ,
x.
f
,., .... 1.
,B. Pumping Record
1. Date of Pumping sate �2. QUanti Pumped: Gallons
3. Type•of system`: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6: System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo tier ° e contents were disposed:
(G-LS'.0 Lowell Waste Water
Si—grikuhi cf Haule Date
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