HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 CHRISTIAN WAY 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 '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/Righ use, Left/Right rear of house, Left/right side of house, Left
Right side of buil ing, Left Right front f building, Left I Right rear of building, Under deck
on the computer, /�
use only the tab /-3d CM"
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key to move your Address
cursor-do not g� G( MA
key the return C /Town State Zip Code
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2. S stem Owner:
Name
renm
Address(if different from location)
_ MA
City/Town State � -_._ Z Cod e
Telephone Number 'l
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): A__8eptic
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4. Effluent Tee Filter present? ❑ Ywt <0 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu 7eW
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6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Loc ' where contents were disposed:
GLSD Lowell Waste Water l
Signature of Hauler Date