HomeMy WebLinkAboutSeptic Pumping Slip - 224 CARLTON LANE 12/2/2015 i
Commonwealth of Massachusetts
= City/Town of
System Pumping-Record
Form 4
1
DEP has provided this farm 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.
j
A. Facility Information
........:�::_
1. System Location: Left/Right front of house, Left i ht rear of horse, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
• Address
Citylrown State Zip Code
d(
2. System Owner.
M.
Name'
Address(if different from location)
City/i'own State'-r7 .�.�. � �'p•�° �' ��
.,.,
Telephone Number
i
B. Pumping Record , —
1. Date of Pumping Date 2. Quantity Pumped: Canons
3. Type-of system: ❑ Cesspool(s) 6p is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3o if yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste -62 fiZ
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. 7GT i ere contents were disposed:
L S. Lowell Waste Water
C
SignjWe fHauleV Date
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