HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 109 FOREST STREET 12/13/2021 : Commonwealth of Massachusetts
City/Town of
j 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 h
the local Board of Health or other approving authority.
A. Facility Information
1. Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side f building, Left/Right front of building, Left/Right rear of building, Under deck
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2. System n
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Address(if different from location)
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Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s),eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Ye 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. Loc where contents were disposed:
LSD Lowell Waste er
Signature of Hauler Date /