HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 371 SUMMER STREET 12/13/2021 : Commonwealth of Massachusetts
City/Town of
System Pumping Record •
Form 4
911-
DEP has provided this form for use-by local Boards of Health. Other forms maybe*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/Right front of house, Left/Right r se, Left/right side of house, Left
Right side of building, Left/Right front f building, Le Right rear I building, Under deck
on the computer, �j �{, �� C •/
use only the tab
key to move your Addr ss
cursor return
not ��n �/�h 'v V l MA
use the return "�
key. City/Town State Zip Code
2. S stem Owner:
Name
ream —
Address(if different from location)
_ MA
Citylrown State
Zip Code
1� - �33 -0
Telephone Number
B. Pumping Record
4G
1. Date of Pumping ate 2. Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) �epticTank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YeS�"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. Lo cat!Qn where contents were disposed:
GL0 Lowell Waste Wa r
Signature of Hauler j0at �