HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 213 CARLTON LANE 9/20/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record SEP 20 2019
Form 4
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 Information
1. System Location a gh of douse, ft/Right rear of house, Left/right side of house, Left
Right side of bu , Left/Rignt frontof building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2: System Owner. T
Name
Address(if different from location)
GWTown Zip e
Tetephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? �s No
5. GonditioEi of System:
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents-were disposed:
7G L S. Lowell Waste Water
sign We qf HaUWU Date
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