HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 184 CARLTON LANE 11/2/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 hous , L'eft%Rig r ark of house ,Leffi/right side of house, Left
Right side of building, Left/ Right front of bui Ing, Left/ Ig rear of building, Under deck
Address }
City/Town State Zip Coda
2. System Owner.
G�
i
Name
Address(if different from location)
City/Town State Zip Coo
�e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0,-Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lora ti ere contents were disposed,
�L S. Lowell Waste Water
Sign a Haule Date
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