HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 196 SUMMER STREET 12/13/2021 Commonwealth of Massachusetts
City/Town of
s System Pumping Record •
Form 4
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.
k Facility information
1. System Location: eft ig fro ouse, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig ildirig, Left/Right rear of building, Under deck
on the computer, /%` , ���9
use only the tab (Q S�'%[�
key to move your MA nPR4
//�iurJVT/ �✓ / 1
cursor-do not �
use the return
key. ( ity town State Zip Code
2. System Owner:
Name
mrtm
Address(if different from location)
MA
City/Town Stat ZipCode
e//A 6.1
Telephone Number
B. Pumping Record �,-v
1. Date of Pumping ( 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) *Septic Tank ❑ Tight Tank ❑ Grea e Trap
P
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No I,f 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. Loc where contents were disposed:
LSD Lowell Waste Water ;
i
Signature of Hauler Date