HomeMy WebLinkAbout- Septic Pumping Slip - 105 CARLTON LANE 9/24/2018 Commonwealthof Massachusetts
Cit�/Town of
y t m Pumpling.Record
Form 4
DBP has provided this for.M far 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 forms,check with your
local ward of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority. 1
A. Facill.ty. lnforlri ation
1. System Location; Lod/Right front of house,Cqwl Right ea of h sou )Left/right side of house, Left/
Right side of building, Lei/Right front of buiidirig, Left/Right rear of building, Under deck
Address
r 1" ,,,,o , ...
"t
�"iity/rown State Zip code
2. System Owner.
c
I
Address Of different from locatlan)
cityrrown " State Zip Cade
'retephane Num er
,r
. Pumping Ripcord `.,
L C)
1. ®ate of Pumping u t - :Quantity Pumped: Gallons
3. Type-of system: El Cesspools) 91septicTank E] Tight Tank j.
Other(describe):
4. Effluent Tee Filter present? Yet No If yes, was it cleaned? Yes El No
5. Condition of System:
6: System Pumped By;
Dell.Bat ors F5821 j
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. La contente,were disposed:
r, ^7_where
'B Lowell Waste Water
Sign a Houle mate
1
15form4.doe-08/03 System Pumping Record•Page 1 of 1