HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 151 CARLTON LANE 4/19/2022 RECEIVED
Commonwealth of Massachusetts APR 19 2022
City/Town of
6 OF NORTH
System Pumping Record TOEALLTH DEPARTMENTER
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybeused, 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 Locabon: Left/X. Right
Ouse, Left/Right rear of house, Left./right side of house, Left
Right side of building, Lront f building, Left/Right rear of building, Under deck
on the computer, C �O use only the tab �j ^
key to move your Addrpss
cursor-do not /U(A& / MA G i C
use the return City/Town State Zip Code
key.
2. System Owner:
/ c�
'icy amyl a ---
rerun
Address(if different from location)
_ MA
City/Town S Zip Code
96
Telephone Number
B. Pumping Record SX�_ -22
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p ped:
6. System Pumped By:
David Tiney _ _ _ _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Loc i here contents were disposed:
rLSD Lowell Waste Wat r
Signature of Hauler Date