HomeMy WebLinkAboutSeptic Pumping Slip - 37 CARLTON LANE 5/1/2018 Commonwe'alth ®f Massachuseffs
RECEIVED
UWTown of
Pumpling.Record
Form 4 1`0 WN Or,N01`111,iMO ���u'
DEP has provided this fora for use-by local Boards 6f Wealth. Other form's may be'used,but the
information,must be substantially the tame as that provided here. Before using,this form,check with your
local Board of Wealth to determine the form they use.The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility. 1 f r fr
ir
1 Right System
sideof building, L f Right front of
Right front of bui deft/ h 4s
R Left rear of.h Left/
/right side c f house, Left/
g rear of building, Under deck
Address �'�.`."/ /1�'✓'�:ma •�'a,"•`J`�.., �..--�'"�..."''1`'+'l.t' �]� � `,,�.�'J�- ��",c" �w°��J�;..
City/'Town state Zip Cotle
2, System Owner: ) .
• • Nama
Address(if different from location)
c4trown ' State � � Zip Code
'telephone Number
mn Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons '
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank t,
❑
Other(describe):
4.. Effluent Tee Filter present?' El Yes o If yes, was it cleaned? Yes ® No,
5. Condition of Syste
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Dumber
Bateson Enterprises Ina
Company
7. Loc;Oonmv here. ontents were disposed:
I—Signe
Lowell Waste Water Hauls Bate
t5form4.doc-06/03 System Pumping Record•page 1 of 1