HomeMy WebLinkAboutSeptic Pumping Slip - 129 CARLTON LANE 5/24/2017Commonwealth of Massachuse
City/Town of
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• bEALTI DEPAR
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 withyour
jto our
local Board of Health to determine the form they use. The System Pumping Record must be subm'tte
the local Board of Health or other approving authority.
A, Facility infor
1. System Locatio gh ront of house Left/ Right rear of house, Left/ right side of house, Left /
Right side of buil ng, Left / Right front o buildirig, Left / Right rear of building, Under deck
Address
I
Ctty/Town
2. System Owner:
Name
te
Zip Code
Address (if different from ion)
City/Town •
State
Zip Code
(
Telephone Number
r
P
P g
1. Date of Pumping
3. Type4:)f system': 0
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
d
Cesspool(s)
Condition of System:
r uck
2. Quantity Pumped:
ptic Tank 0 Tight Tank
If yes, was it cleaned? LJ Yes 0 No,
A,
6: System Pumped By:
Neil. Bateson
• Name
Bateson Enterprises Inc
Company
7. Location Where contents were disposed:
Lowell Waste Water
°Id
F5821
Vehicle License Number
t5forrn4.doc. 06/03
System Pumping Record Page 1 of 1