HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 44 CARLTON LANE 4/9/2021 (3) Commonwealth of Massachusetts
City/Town of APR o 2021
System Pumping Record CF HE I,a
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 �ejt/Right r of houser Left/right side of house, Left
Right side of building, Left/ Right front of bu`i ing, Left/Right rear of building, Under deck
Address i j L � �— �
City/Town `� State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dais 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-Sel the Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ej--N-o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
7-1C
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo;'t—LL!
re contents were disposed:
S: Lowell Waste Water
Signitute fHauleUDate
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