HomeMy WebLinkAboutSeptic Pumping Slip - 44 CARLTON LANE 12/17/2015 I
Commonwealth of Massachusetts
City/Town of j
y� tem Pumping-Record
Form 4
t
DEP has provided this form for usezby local Boards of Health. Other forms.may b 'qs d, 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 house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
U L. ' . .µms.._.
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town - State _� .�..� Zip Code ;
Telephone Number
i
B. Pumping Record .
4 - c
1. Date of Pumping Date 2. Quantity Pumped: Gallons —`
3. Type-of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locat,. n her contents were disposed:
G L S. Lowell Waste Water
cr,
IF
SignAhle I HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1