HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1510 SALEM STREET 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 may 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 form 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/RI
I-Qbt rear of ho se, Left/right side of house, Left
on the computer
Right side of building, Left/Righ front of building, eft/ ght�f building, Under deck
use only the tab, '_
key to move your 14ddre s
cursor- not " MA
use the return
key. City/Town State Zip Code
2. Syst wner.
Name - --
raem
Address(if different from location)
MA
City/Town State
q _ Zip C de
Telephone Number
B. Pumping Record l /'
1. Date of Pumping — 2. Quanti Pum ed: 50—
Date tY p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: -2
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