HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 CARLTON LANE 4/9/2021 Commonwealth of Massachusetts �✓ ,d��
City/Town of APR o 2021
System Pumping Record - OF HEALTH
Form 4
DEP has provided this form for us&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 housef�e /Right r of houses Left/right side of house, Left/
Right side of building, Left/Right front of but ing, Left/Right rear of building, Under deck
Address
CiWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Zip Code
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 ❑=t4o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systecr
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio re contents-were disposed:
L S Lowell Waste Water
'7::3: t
Sign a I-HauleV Date
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