HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 MILL 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 may be bsed,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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right fro se, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Ro&fr6nt o building, Left/Right rear of building, Under deck
on the computer,
use only the tab `
key to move your A dress
cursor-do not '_' , i/t` ( MA
use the return
key. City/town State Zip Code
2. Syst m Owner:
Name
Bnm
Address(if different from location)
MA
Cityrrown Statue Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)-
4. Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo�n,�nt pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc bon where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date