HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 69 OAKES DRIVE 1/31/2022 ,�L\ Commonwealth of Massachusetts
City/Town of RECEIVED
system Pumping Record •
Form 4 JAN 312022
To
DEP has provided this form for use-by local Boards of Health. Other uf 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 Locabon: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
on the computer, 31 09 p� -�
use only the tab
key to move your Address
cursor-do not A 1 Pon w Q<— MA
use the return key. City/i own State Zip Code
2. System Owner: �\
Name
renm '
Address(if different from location)
_ MA
Cityrrown State A Zip Code
Telep—h'7onnne Number
B. Pumping Record
1 rt�
1. Date of Pumping Da e -1 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Ob rued 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:
GLSD Lowell Waste Water
-_ _
Signature of Hauler Date r