HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 177 CARLTON LANE 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 0
System Pumping Record TOWN 6F NORTH AN
Form 4
HEALTH Ci PARTMEN7 R
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, Left/Right rear of house, Left/rq4httside of hous ,Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(d different from location)
City/Town S
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ,� � A-A-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.Isign
are contents were disposed:
Lowell Waste Water
a;Haurig Date
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