HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 213 CARLTON LANE 8/10/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AU0 10 2020
System Pumping Record TOWN NURTMANDU
Y N g HEALTH
ALTH DEPARTMENT
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 Locatioif—Leftj RighW6Ft of house, /Right rear of house, Left/right side of house, Left
Right side of building, Left/Right ron o uildirig, Left/Right rear of building, Under deck
Address
� L
awrown State Zip Code
2. System Owner.
r
Name
Address(if different from location)
Cityrrown State Zip Code
S 6
Telephone Number
B. Pumping Record
1. Date of Pumping oat a� 2- Quantity Pumped: DPIons
—
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Qom❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
Sign a Haul Dal
t5form4.doc•06/03 System Pumping Record•Page 1 of 1