HomeMy WebLinkAboutSeptic Pumping Slip - 224 CARLTON LANE 12/5/2017 : Commonwealth of Massachusetts
z CitylTown of .
v° System Pumping.Record
Farm 4
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
focal Board of Health to determine the fornt they use.The System Pumping Record must be submitted to
the local.Board of Health or other approving authority.
A. Facility. InforMa#ion
1. System Location: Left/Right front of douse, Left/Right rear of house, Left-/right side of house, Lett
Right side of building, Left 1 Rigl t front of buildirig, Left 1 Right rear of building, Under deck
Address
City/7own State Zip Code
2. System Owner. v�
Name'
Address(if different from location)
Citylrown ' State�r�
i " c
Telephone Number
3 j
.B. Pumping Record
C�
1. Date of Pumping Date 2. Quantlty Pumped:
Gallons Y
3. Type-of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
S. Condition of System: �, �
6: System Pumped By:
Nell.Bateson - F5821
Name Vehicle license Number
Bateson Enterprises Ina
Company
• p
7. Lo he contents-were disposed:
G L S: Lowell Waste Water p
F
SignkuFe Ftbule Date
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