HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 12/13/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record 16
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may *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/Rig house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Le $Right front f buildirig, Left/Right rear of building, Under deck
on the computer, ("� ,/ ►� /�
use only the tab v C 4 �. -� �'` A (/
key to move your Addy ss /
cursor-do not t�y 1N► �� s� MA Q y�
use the return 'Ci /T 11��
key. own State Zip Code
2. Sys m Ow er:
��� (a
Name
renm .
Address(if different from location)
MA
City/Town State Zip Code
33
Telephone Number
B. Pumping Record
1. Date of Pumping / I 2. Quantity Pumped:
Datee Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)-
4. Effluent Tee Filter present? ❑ Yes.A�rNo 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. Lo ' n where contents were disposed:
LSD Lowell Waste Water
- 1-a
Signature of Hauler Date