HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 769 FOREST STREET 12/13/2021 : Commonwealth of Massachusetts
City/Town of
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 form they use.The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
k Facility Information
1. System Location: Left/Right front of house, Left/Right rear of hqRse, Left/right side of house, Left
Right side of building, Left/Right front of buildifig6efk/Right ear �f building, Under deck
on the computer, / ��\ �C ����
use only the tab
key to move your Vityfrown
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cursor-do not �J �� 2 MA ( �
use the return
key. State Zip Code
2. System Owner:
k)1150
Name
ream
Address(if different from location)
MA
Cityrrown State �foa Zip Code
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Telephone Number
B. Pumping Record
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1. Date of Pumping 2. Quantity Pumped: —
Date p Gallons
3. Component: ❑ Cesspool(s) "Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesJ No 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. ion where contents were disposed:
GLS Lowell Waste ater
-r-- _
Signature of Hauler Date