HomeMy WebLinkAboutSeptic Pumping Slip - 151 CARLTON LANE 4/24/2018 Commonwealth of Massachusetts
w 1 n o pf /e f it {Vn n{Win
r 'rSyjtem Pumping.Record
Form 4
DEP has provided this form for use-by local Boards 6Mealth. Other forms may be'utd&"
information-must be substantially the.tame as that provided here. Before using.this form,deck with your
local Board of Health to determine the forrh they use.The:system Pumping Record must be submltted to
the local Board of Health or other approving authority.
A. Factfity. I o i
1. System Location: Leh t front of Mous Left/Right rear of house, Left./right side of house, Left/
Right side of building, Left/Rig r� oo building, Left/Right rear of building, Under deck
Address '
City/rown state Zip Code
2. System Owner:
Name.
Address(if different from location)
City/Town Stat a
Telephone Number
1
® Pumping Rpeord
1. ®ate of Pumping Date Gallons 2. Quantity Pumped: _-
3. Type-of systerri: El Cesspools) ept'te Tank ® Tight Tank
El Other(describe):
4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? ® Yes ® No,
" 5. Condition of System: � / P ••, �, ("� �`w'�,�����---
6: System Pumped Ey:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo where contents-were disposed:
C - Lowell Waste Water
SignAtoo 0bule Date
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