HomeMy WebLinkAboutSeptic Pumping Slip - 184 CARLTON LANE 11/17/2017 Damm wealth of Massachusetts �
Sy.Wm Pumping-Record
Form 4 JiEAUTDw't4 OF:�i DE R E a r
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 Hous e ighi ear d hos , Left/right side of house, Left
Right side of building, Left/Right front of bul Trig, Left/Rig rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zi Code
Telephone Number �` t
i
. Pumping Record
1, ®ate of Pumping Date 2. Quantity Pumped:
Gallons---i__—�
3. Type-of system: (l Cesspool(s) E pfc Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes ,. if yes, was it cleaned? E Yes [3 No,
' 5. Condition of System:
6: System Pumped By: }
Nell.Bateson F5821 j
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
C L S: Lowell Waste Water
4AaA (3
*7
Sign a Haule Date
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