HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1550 SALEM 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 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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right f housl3, Left/right side of house, Left
Right side of building, eft/Right front of building, Left Right rear �f building, Under deck
;on the computer, /, 3,g ,^
use only the tab
key to move your Addres
cursor-do not �A L MA �
use the return ity� State -
key. Zip Code
�1 2. System Owner:
Name
B�
Address(if different from location)
MA
City/Town State28/— 3Q? Zip Coe �
Telephone Number U Y /`7/
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. I No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu T d:
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locat�LSD
where contents were disposed:
Lowell Waste Water 01
Signature of Hauler Date