HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 FOREST STREET 12/13/2021 :Y Commonwealth of Massachusetts
City/Town of
b 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 t(
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of house, Left/Right re use, Left/right side of house, Left
Right side of building, Left/Right front of building, Left ht
on the computer, rear building, Under deck
( � �Q y�
use only the tab `t.�:>
key to move your Addrpfs, (�
cursor-do not r � � ��� MA
use the return City/Town
key. State Zip Code
2. Sys Owner:
Name
wnm
Address(if different from location) --
MA
City/Town State _ Zip Code
Telephone Number
B. Pumping Record ' � 1
1. Date of Pumping /2--J _L� L
p g ate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Greage Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Ye�o 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. L where contents were disposed:
GLSD Lowell Waste Water
C
Signature of Hauler Date