HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 212 HAY MEADOW ROAD 12/13/2021 Commonwealth of Massachusetts
City/Town of
b System Pumping Record
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 font,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: Leh/Right front of house, Left/Right r use, Left/right side of house, Left
Righ side of building, Left/Right front of building, Left Right rear if building, Under deck
on the computer,
use only the tab `
key to move your Pddsscursor-do not MA G1use the returnkey. own State Zip Code
S 2. Syste Ow
Name -
Ron
Address(if different from location)
— MA
City/Town State //'' NO—
' de
er2) '
Zeph.Xumb �
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: `
Date Gallons -
3. Component: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- --
4. Effluent Tee Filter present? ❑ Y'j:,j No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
V�1C/1
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
Date
Signature of Hauler