HomeMy WebLinkAboutSeptic Pumping Slip - 189 CARLTON LANE 7/2/2018 Commonwealth of Massachusetts
City/Town of
aSyiftm Pumping.
Form 4
DEP has provided this form for use by local Boards of Health. Other forms maybe bsed,but the
information-must be substantially the same as that provided here. Before using.this fora,Check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted�a
the local Board of Health or other approving authority.
A. FaclPty, Infor Mation..
1. System Locatio . /ftigh tort pf house eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig6t front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. system Owner:
' N�JmO
Address(if different from locafion)
Ci awn State[• —10/+J� ''f')
'telephone Number �• °'
. Pumping Ropeord
r ,
1. Cate of Pumping cote 2. Quantity Pumped:
Gallons
3. Type-of systeffi: El Cesspool(s) 4 eptic Tank Q Tight Tank ,
Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ❑ Yes ® No.
5. Condition of System*
6. System Pumped By:
Neil.Bstesa� F'5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati ;hare contents-were disposed:G L SLowell Waste Water
Sign F9hul ®ate
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