HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 CARLTON LANE 10/16/2019 :-C\- Commonwealth of Massachusetts
= City/Town of
System Pumping Record
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: Left/Right front of house, Left/kii�t rear of house,\ Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address
city/rown State Zip Code
2 System Owner.
Name
Address(if different from location)
CiWown gtat Zip
900
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool($) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D—No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst _A/C � — L1 � V
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L he contents-were disposed:
GLSQ Lowell Waste Water
C
Sign We cf Ha—ulevDate
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