HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 LACONIA CIRCLE 12/13/2021 : Commonwealth of Massachusetts
City/Town of
z 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 form,check with you
local Board of Health to determine the forrh 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 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, I ,^ c��v I—A Lx`
use only the tab (—.(J� r
key to move your A r s
cursor-do not b MA
use the return t/Ci !Town
key. h` State Zip Code
2. System Owner:
Name _
mnen
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number `
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
� �G
Date ty p Gallons
3. Component: ❑ Cesspool(s) Septic 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
4&!� - &
Signature of Hauler I Date