HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 189 CARLTON LANE 8/2/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record ®��9Ma���v��
Form 4 °f®0��N10������
DEP has provided this form for use=by local Boards of Health. Other forms may be used,but the'
information•must be substantially the same 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 Inforrr9ation
: e foio f1. System Locati Right rear of house, Left/right side of house, Left
Right side of building, Left Ig ron of building, Left/Right rear of building, Under deck
i
Address LOLA__�,e
CWTown State Zip Code
Z. System Owner.
Name'
Address(if different from location)
CitylTawn State e�'
Telephone Number
.B. Pumping Record
1. Date of Pumping �2_ Quanti Pumped:DateGallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ek o if yes, was it cleaned? ❑- Yes ❑ No'
5. Condition of System:
6. system Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo . whe contents-were disposed:
G L S Lowell Waste Water
I?
Sign We cf HaulwU Date
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