HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FOREST STREET 12/13/2021 Commonwealth of Massachusetts
City/Town of
t System Pumping Record 10
Form 4
DEP has provided this form for use-by local Boards of flealth. 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/ rear of e, Left 1 right side of house, Left
Righ side of bul ding, Left/Right front of building Left" Righ rear f building, Under deck
on the computer, �� Q J — C
use only the tab JT cam_
key to move your Acme;s_,,�. / - — !,cursor-do not f V b-q - _ MA ��� `7
use the return
key. Cityrrown State Zip Code
2. System Owner: All
1
aml� - -
Address(if different from location) —
MA
Cityrrown State Code
1
Telephone Number
B. Pumping Record
S—91
1. Date of Pumping - I /� n/
2. Quantity Pumped: ` _C)
Date Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe): xSeptic
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4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
W
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