HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 COLONIAL AVENUE 1/31/2022 ;_C_\ Commonwealth of Massachusetts NECEIVEC
City/Town of
b System Pumping Record 4 JAN 31 2022
Form 4 TOWN OF NOR-rH ANDCVE"
HEALTH DEPARTMUl',"
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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, LeiffiJ Rig ear of house ft/right side of house, Left
Right side of building, Left/ Right front of bulidirig, Left/Rig rear of building, Under deck
on the computer,
use only the tab —1 ( d� b�.0 F •t _� � N C.�
key to move your Address
cursor-do not MA
use the return key. Cityfrown State Zip Code
,n
2. System Owner:
LA 14
Name
enm 4.r -- --------- —
Address(if different from location)
MA
Cityrrown State Zip Code
a i o �E7
Telephone Number
B. Pumping Record
1. Date of Pumping Daft 2. Quantity Pumped: Gall ns
C O
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed 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