HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 CARLTON LANE 9/29/2021 Commonwealth of Massachusetts 77
Q City/Town of
21
System Pumping Record SK-1P 2 K,
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 tame as that provided here. Before using.this form,check with your
[owl Board of Health to determine the brrh 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 JgWrear of house eft. .T::a�:qf=hous�l_ -/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 4 W—kA-�
Myfrown State Zip Code
2. System Owner cc-,-CcL
Name
Address(if different from location)
CityfTown Zin Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: diio-ris
3. Type-of system: ❑ Cesspool(s) ate—ptic Tank M Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes,was it cleaned? ❑ Yes El No
5. Condition of System: V\,
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
AL Lowell Waste Water
C-NraSA.
Data
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