HomeMy WebLinkAbout- Septic Pumping Slip - 249 CARLTON LANE 6/4/2019 ' Ith o Massachuseffs
Commonwea
City/Tow
# AY
System Pumping Record a
Form 4 ✓�oev!If r�rfr�o�0 JI��1-4°'b,IQ, M f�n" ^aII I4 Jt W ti'F
i
OtherDEP has provided this form for use.by local Boards of,Health., formis maybebsed,but the
information,must be!substintially the tame as that provided here. Blefore using.this
1 ,i Board of'Health to
determine
r form' they
use.'Tbe$ystern
Pumpling must be submitted �,
h l l l i M�
o
A. Facility Inform' afloon
I r"ght side of house, Left/System Location: Left/Right,front of e �W
sibuildingde 1 nt of bui �n h� rear cif building, Under deck
Address "C 1�4en"
Mytrown State Zip Code
62 Z., System Owner.
Address Of different fto m, to
CityfTown Zip Codle
t r
d
PumpingB. Pumping Record ( C
1. Date of Data . Qua*nt.lty Pumped,: Gallons
t
3. Type-of system: Cesspool(s) 0. 1-,19e�,pfic Tk Tight Tank
r
Other
(describe):
t
4. Effluent Tee Filter present? El
Y If yes, was,it cleaned?, Ej Yes No
ConditionC.,
1
5. l
Nell.6, Systern, Pumped By:
Batesibn M58121
Narne
4
VehicleNumber
Bateson
teTLIses Ina
Company
. L contentsr i
Lowell
l Date
t`' 0,6/03 Syste m, Pum,pingr a Page 1 of 1