HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 252 GRAY STREET 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 tame 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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Le ;htron�ront
ouse, Left/Right rear of housa, Left/right side of house, Left
Right side of buildin , Leftgh of building, Left/Right rear of building, Under deck
on the computer,
use only the tab AY �
key to move your s �/
cursor-do not MA7j
use the return Ci /Town
key. �' State Zip Code
2. Stem Owner:F
Name
ream Address(if different from location) —
MA
Cityrrown State Zip Code
W r) cnd
Telephone Number
B. Pumping Record
1. Date of Pumping " f`30
2. Quantity Pumped:
Date um p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yer'� o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
oe
6. System Pumped By:
David Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. L ti where contents were disposed:
GLS Lowell Waste Water
Signature of Ha r Da e