HomeMy WebLinkAbout- Septic Pumping Slip - 184 CARLTON LANE 10/19/2018 Commonwealth ®f Massachusetts
City/Town of FRECESIVIED
System Pumpino Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe **14d",
information-must be substantially the tame as that provided here. 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. Facility InforMation
1. System Location: Left/Right front of house,(ta�R!ghkNij6,EQ�M Left./right side of house, Left I
Right side of building, Left Right front of building, Left Wight rear of building, Under de'ck
Address
LV-\
ctw/Town state Zip Cone
2. System Owner.
Name'
Address(if different from location)
City/Town State,�,,,
Code
d
telephone Number
.B. Pumpling Record
V-)
1, Date of Pumping 2. Quantity Pumped:
Hate Gallons
3. Type-of system, El Cesspool($) Dls�eprlc Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? E] Yes 0140 If yes, was it cleaned? [j Yes No
5. Condition of System:
CA-
6. System Pumped By:
Nell.Bates7bri F5821
Name Vehicle License Number
Bateson Enterprises Inc
company
7. Lotion wh p content were disposed:
Lowell Waste Water
sign Hb u!WU Date
t5fbrm4.dor.-08/03 System Pumping Record-Page 1 of 1