HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 DUNCAN DRIVE 12/13/2021 Commonwealth of Massachusetts
City/Town of
b 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.
k Facility information
1. cation: Left/Right front of house, Left/Right rear of housa, Left/right side of house, Left
'R;Jghrts�fd�e�bf buildi�n-�, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, r rI 1'. „ JC,n� , 01 ,
use only the tab J 4��1.�y ,"y'�.+ �1
key to move your Address ��
cursor-do not i/y G �( MA [/
use the return key. ity[Town State Zip Code
2. System Owner:
dCA t)ib�j
it Name
renm
Address(if different from location)
_ MA
Cityrrown State C_9�� Zip Code
r 5G [
Telephone Number
B. Pumping Record /
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1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) —*Septic Tank ❑ Tight Tank ❑ Grea*e Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes*
es No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pujmped*
--— �
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LS Lowell Wastp Water
_ A011- 9 01'q/
Signature of Hauler Date