HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 BRIDGES LANE 1/31/2022 Commonwealth of Massachusetts BECEIVEC
UCity/Town of
System Pumping Record JAN 312022
Form 4
TOWN OFIdGP+TH gNDOVEF?
r- l T,I DEPARTMENIT
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 1 ht front of house eft/Right rear of house, Left/right side of house, Left
Right side of building, Le Ight ron o building, Left/Right rear of building, Under deck
on the computer,use only the tab 13 r1-
L/�
key to move your Address
cursor-do not MA
use MA l
use the return
key. City/Town State Zip Code
2. System Owner:
,n (-
Name
renm
Address(if different from location)
__ MA
City/Town State Zip Code
5--)
4
Telephone-N umber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: allons
3. Component: ❑ Cesspool(s) _1�1,� ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c`mponenntumped:
X-Inner
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
SD Lowell ante Water
Signatur f Ha er Date