HomeMy WebLinkAboutSeptic Tank - Pump Chamber - Septic Pumping Slip - 10 TANGLEWOOD LANE 12/13/2021 Commonwealth of Massachusetts
City/Town of
5 System Pumping Record 10
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'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 t(
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, /� --}—/n,, / _ _ /J
use only the tab (J ` !�7/'� �1..Q (J��C�jY.�'
key to move your Rds�% — —
cursor- not MA Y
use the return
urn City/Town State key. Zip Code
2. Sys pm Ow er:
VkA
Name
rerun
Address(if different from location)
_____ MA
City/Town State Zip Code
�- �3
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: -
Gallons
3. Component: ❑ Cesspool(s) .Meptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? El 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 Date