HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 CARLTON LANE 4/1/2020 :j L\ Commonwealth of Massachusetts APR
City/Town of , 12020
TOYM OFIVOR System m Pumping Record HEALTq D, J-
ANDO
DEP has provided this form for use by local Boards of Health. Other forms may beused, but the
inf9ormation-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh 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 #front of hou Left/Right rear of house, Left/right side of house, Leff:
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address L S I
CityRown State Zip Code
2. System Owner.
Name"
Address(if different from lopfion)
City/Town State e
Telephone Number
.B. 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? ❑ Yes 4.J��� 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 h e contents-were disposed:
G L S. Lowell Waste Water
�3_fa_c)c
Sign a llhul Date
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