HomeMy WebLinkAbout- Septic Pumping Slip - 213 CARLTON LANE 9/24/2018 Commonwe,91th of Massachusefts
1 n ,
Pumpling.Record ,� CK
Form 4
p P has provided this form for use-by local Boards of Health. Other forms 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 Health to determine the forrh they use. The System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. I i li I r .. .
1. System Location: light runt of tio
es Lett/Right rear of house, Left/right aids of house, Left/
Right side of building, Left/Right front of buildifng, Left/Hight rear of building, Under deck
Address
City/Town Stake Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' state.
d '
e
Telephone Number ,
b t
Ppmpling
- r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
f
3, Type-of system: El Cesspool(s) p is Tank ❑ Tight Tank '
Other(describe):
4. Effluent Tee Filter present? ® No If yes, was it cleaned? es No.
' 5, Condition of System,
`a
System Pumped By:
�'rU' a- f✓. C' ' , —L,•
6: S
y p
Nell.Bateseon ' F5821
Name Vehicle License Number i
Bateson Enterprises Inc,
Company
7. Loca'on. �� content&were disposed:
C Lowell Waste Water
Sign a Haut Date
tMrm4.docb 06/03 System Pumping Record.Page 1 of 1