HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 SALEM STREET 12/13/2021 Commonwealth of Massachusetts
City/Town of
j System Pumping Record •
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybeused,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 Information
1. System Location: Left/Right front of house, Left/Right reaEPfliqyse, Left./right side of house, Left
Right side of building, Left/Right front of building, Left/ ght rear f building, Under deck
on the computer, �r �� n
use only the tab
key to move your Rddre
cursor-do not ,IG/w( MA
use the return City/Town State key. Zip Code
2. S m Owner:
Name --
warn
Address(if different from location)
MA
Cityrrown State
V Code
C
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: J
Date Gallons
3. Component: ❑ Cesspool(s) dseptic 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:
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 p
4�� date - 3 na