HomeMy WebLinkAbout- Septic Pumping Slip - 133 COLONIAL AVENUE 12/13/2021 : Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of'Health. Other forms maybe 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 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
on the computer,
use only the tab
key to move your ddres
cursor-do not �nq �� MA Q`�-1
use the return
key. City/Town State
Zip Code
k2. System Owner:
C6oe G<sJ--e/A)
Name f --
21un
Address(if different from location)
_ MA
CitylTown State l/ 7n Code
��'9 r✓ �/ 'Zip /
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: C1�
Date —
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes jNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�G
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date