HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 177 CARLTON LANE 10/31/2022 RECEIVED
: Commonwealth of Massachusetts OCT 312022
City/Town of
t Y Pumping DEPART
FormF NORTH System Pum fin 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 you
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left/Right rear of house, Left right 'de of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, er deck
on the computer,
use only the tab �� CcT� tG !�2
key to move your Address
cursor-do not 1 /� �1�_�
use the return MA
�C`'ty��`—olswln State key. Zip Code
2. System Owner:
Name
nnm
Address(if different from location)
MA
Cityfrown State
Zip Code
ram(- -
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z, -- 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) X Septic 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 pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Lowell Waste Water
61gftqture oft uler ( k�
Date