HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 HAY MEADOW 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'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 ht front o ouse, Left/Right rear of house, Left/right side of house, Left
Right side of buildin Left Righ ront building, Left/Right rear of building, Under deck
on the computer, 7 n
use only the tab _? ('j' RcJ
key to move your Address
cursor-do not C VA-A, MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Bnm
Address(if different from location)
MA
City/Town State/ / 14i' Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. QuantityPumped:
Date p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Greage Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,,P<No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump d:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Co any
7. Lo n where contents were disposed:
GLSD Lowell Waste ater
4$�� _ - -I-1-C2 �- --- --
Signature of Hauler A Date