HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 209 BRIDGES LANE 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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of hous Left/ t rear f house, Left/right side of house, Left
Right side of building, Left/Righ/t�front of bul g t rear of building, Under deck
on the computer, n f_�;� `-' L/ V. - — -
use only the tab �/V l I'� C:`
key to move your -Ad ress (� 7—
cursor-do not R 4{ MA
use the return key. City/Town State Zip Code
2. S stem Owner:
ame
rertm
Address(if different from location)
MA
City/Town St�te�^ ,r � � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date V 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): �,/ -
4. Effluent Tee Filter present? ,ICI Yes ❑ 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. Location where contents were disposed:
LSD Lowell Was!p Water
Signature of HauleV Date