HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 JOHNNY CAKE STREET 12/13/2021 : Commonwealth of Massachusetts
City/Town of
b System Pumping Record10
Form 4
DEP has provided this form for use-by local Boards of Health. other forms may 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 forrh they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. Syste tlon: Left/Right front of house, Left/Right rear of house, Left/right side of house, eft
Rig fde f bit i(dintl
Left/Right front of building, Left/Right rear of building, Under deck
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key the return Cry—� State Zip Code
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2. Syste wner;
Name
ream
Address(if different from location)
MA
Cityrrown State i Code
Telephone Number
B. Pumping Record 11-2
1. Date of Pumping ate 2. Quantity Pumped: canons
3. Component: ❑ Cesspool(s) N&eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesXNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
SD . Lowell Waste Water
Signature of Hauler v hat