HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 CARLTON LANE 4/19/2022 RECEIVt_4.'
Commonwealth of Massachusetts
City/Town of APR 19 2U�.1
TOWN OF NORTH AND
System Pumping Record
Form 4 HEALTH DEPARTMENT
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 you
local Board of Health to determine the form they use.The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/RlghVearvfbouse, Left/right side of house, Left
Right side of b 'Iding, Left/Right front of building, LeK Right rear o uilding, Under deck
on the computer, ,
use only the tab �rn
key to move your Ad�r si'[ " �
cursor-do not ��.///1/ 14 4av?- _ MA y
use the return Cityrrown State Zip Code
key.
2. Sys Owner:
(3 jo Iq A 0
Name
rerun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date