HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1551 OSGOOD STREET 1/31/2022 Commonwealth of Massachusetts HECOVED
City/Town of JAN 312022
System Pumping Record
Form 4 TOHEN OF NORTH EB
HEALTH DEPARTMENT
ul
DEP has provided this form for use-by local Boards of Health. Outer 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/ ' ht front of se, Left/ Right rear of house, Left/right side of house, Left
Right side of buiidin Le Right eon f building, Left/Right rear of building, Under deck
on the computer,
use only the tab J
key to move your ddress
cursor-do not (f) MA
use the return ty/Town State Zip Code
key.
2. System Owner:
RI'CA6 "��
-Name
rerun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record P1
1. Date of Pumping Dane 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): - —
4. Effluent Tee Filter present? ❑ Yes�1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
L�
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7.jLoc '7where contents were disposed:
SLowell Waste Water
Signature of Hauler Date