HomeMy WebLinkAboutSeptic Pumping Slip - 249 CARLTON LANE 6/1/2017 Commonwealth Massachusetts -CEIVEDRE
Cjt�/Town of
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QSyMem Pumping.
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Form. 4 VoLlIj DEPART
DEP has provided this fora for use.,by local Boards of Health. Other fords may b 'u ed,but the
informadon�must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted f
the local ward of Health or other approving authority.
A. Facl-14Y. Information
I. System Location: Left/Right front pf house, Left 1 Right rear of house, Left/right side of house, Left/
fiRight side of building, Left/Right front of building, Left/Right rear of building, lander deck
Address
City/Torr� Mete Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown , stat - . C..t 4
jp Code
t
Telephone Number
® Pumping
1. Date of Pumping date Iuantl Pumped: Gallons ,
. Type-of sy terry: Cesspool(s) ;,�eptic Wank El "Tight Tank
Other(describe): -
4. Effluent Tee Filter present? El Yep o If yes, was it cleaned? Yes No.
' 5. Condition of.System: ) `
6.- System Pumped By.
Feil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
!. Location where contents were disposed:
ISIgnt
Lowell Waste Water
Hauls ®ate!/ _J\ 1
t5form4.doc,,08/03 system Pumping Record Fuge°I of 1