HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 PHEASANT BROOK ROAD 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 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/Rkjt#4ear of hDyse, Left/right side of house, Left
Right side of bull ' g, Left/Right front of buildiri , Left`Alg rear Of building, Under deck
on the computer,
use only the tab RA
key to move your A d "ss
cursor-do notuse Q MA
key.the return Cityfrown State Zip Code
2. Sy tem Owner:
arfie
ream
Address(if different from location)
_ MA
Citylrown State ^ Zip Code
oL/ - 9 1zi
Telephone NumberB. Pumping Record k I
1. Date of Pumping Da a 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y o 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. ion yvhere contents were disposed:
LG LS , Lowell Waste Water _
Signature of Hauler Date
