HomeMy WebLinkAboutSeptic Pumping Slip - 189 CARLTON LANE 7/31/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
DEP has provided this form for useby local Boards Of Health. Other forms may be used, but the
informationmust 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 Locatio
Right side of bui
Address
/ ;Zig
g, Left /
f tious4, Left / Right rear of house, Left/ right side of house, Left /
ront of building, Left / Right rear of building, Under deck
City/Town
2. System Owner
State Zip Code
Name
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type.of system 0 Cesspool(s) LjSeptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? 0 Yes El No,
.
5. Condition of System:
(A-L
LA,--k}utiL
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Locati -wherecontents were disposed:
owell Waste Water
F5821
Vehicle License Number
Sign Haule Date
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