HomeMy WebLinkAboutSeptic Pumping Slip - 151 CARLTON LANE 12/13/2016 Commonwealth f Massachusetts
City/Town of RECEIVED
SyMem Pumping.Record
DEC U4,
Form 4
D P has provided this form for use.by local Boards of Health, Other �m FU °811 Tout the
information-must be substantially the erne as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they fuse.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I. Sy tern L® tion: Lift Rift front of us,Left/Right rear of house, Left/right side off house, Left J
r7 Right side of building, Left/Rig ron Fouildirig, Left/Right rear of building, Under deck
Address
City/T'own State Zip Code
2. System Owner: c
Marne"
Address(if different from tocation)
city/Town Met& p
,1 �r Zi Code ;
"telephone Number � c
m
Pumping c r � ..
1. Date of Pumping gate 2. Quantity Pumped:
gallons ��`"
3. Type-of system'. Cesspool(s) epttc Tank El Tight Tank
Other(describe):
4. Effluent.Tee Filter present? Ej Yep if yes, was it cleaned? E Yes Ej No,
5. Condition of.System:
6." System Pumped By:
Nell.Bat can F5821
Name Vehicle License dumber
Sateon Enterprises !nc
Company
7. Loca ere contents were disposed:
L S. Lowell Waste Water
sign a FlauCe T]at®
t5form4.doc-08103 System Pumping Record page 1 of 1