HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 DUNCAN DRIVE 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 forrim 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 r use, Left/right side of house, Left
Right side of building, Left/Right front of building, Left 'ght rear building, Under deck
on the computer, / � _1) r .A)CA�
use only the tab /r (�
key to move your Address
cursor- not Cy �eCL—�G7`�`��� MA
use the return
urn �-V
key. ityfrown State Zip Code
2. Sy tem Owner:
ray
Name
faun �a
Address(if different from location)
_ MA
Cityrrown State Zip Code
6g7- &Y C
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: G
Gallons
3. Component: ❑ Cesspool(s)`',,�4eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes, o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
d
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