HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 FULLER ROAD 12/13/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. 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 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 buildin , eft' Righ ear�f building, Under deck
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use only the tab
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use the return _MA � e�
key. i Town State Zip Code
2. Sys a ner:
Name
mnm
Address(if different from location)
_ MA
Cltyflrown State Zip Code
_ Telephone Number
B. Pumping Record III LAO?
Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----- -- - _ _
4. Effluent Tee Filter present? ❑ Yes4No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: �g
6. System Pumped By:
David Tiney Mass F5821
Name
Vehicle License Number
Bateson Enterprises, Inc.
Company — -
7. L where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date