HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 WINTERGREEN DRIVE 12/13/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record y
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 form they use.The.System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Inform* ation
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of buildirigLeft/Right rear of building, Under deck
on the computer, 3 � f,
use only the tab 1 FA 9 L
key to move your Add r ss � �Q
cursor-do not l "e—2 MA (J/� 1-7S
key the return City).own State Zip Code
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2. Systep Owner:
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Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record _ o
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic 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 component pumped:
- J
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc ' where contents were disposed:
LSD Lowell Waste Water _
Signature of Hauler Date