HomeMy WebLinkAboutSeptic Pumping Slip - 49 CARLTON LANE 6/6/2018 WED
Commonwealth of Massachusetts RWZ'.
CiWow
y tom Pumping.• Record
TOWN
FQrm 4 viva..i n
DEP has provided this forrri for use-by local Boards of Health. Other forts may ba used,but the
information-roust be substantially the tame as that provided Dere. 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. Facill,ty, Information .
1. System Location: Left/Right front of douse, Leftar of��s6, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address
, 1 --,, -L
Cityrrown state Zip Code
2. System Owner: �
Name*
Address(if different from location)
Cifyl�own stat �,_ it~Code
'telephone Number
r
.B. Pumping Rpcord
tt
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of s
yp y.stern:
[] Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ® Yes ® No,
5. Condition of Sys
✓ , 45:�t/LJ�
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises In -
Company
7. Lo 0 ° re contents-were disposed:
GL Lowell Waste Water
. E
gn a Houle Bate
t%orm4.doo~06103 system Pumping Record d Page 1 of 1