HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 CARLTON LANE 6/24/2021 Commonwealth of Massachusetts
City/Town of RECEIVE
System Pumping Record
Form 4
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DEP has provided this form for use-by local Boards of Health. Other forms RW- 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 f�ofh�'ouLeft/Right rear of house, Left/right side of house, LeftRight side of bulll ing, Left/Rilding, Left/Right rear of building, Under deck
Adds ��3 G ��� �� 0(�
City/Town State Zip Code
2. System Owner.
U
Name'
Address(if different from location)
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Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Galloons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ld'No 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. =LS.JDP
contents-were disposed:
Lowell Waste Water
M-WA
- i
Signift6 qt HauleiU Date
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