HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 175 OLD CART WAY 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 forrh 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 rear of house, Left/i htid
house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, neck
on the computer, D
use only the tab / v l
key to move your Ad r s '[�Q/ 1<6
/cursor-do not Lam"— MA �[
key the return City/Town State Zip Code
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2. System O ner:
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ream
Address(if different from location)
MA
City/Town Stl;.-�_ Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping )d-d 2. Quantity Pumped:
Date ry r GkIrons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc where contents were disposed:
LSD Lowell Waste Water
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Signature of Hauler Date