HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 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 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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. Syste tlon: Left/Right front of house, Left/Right rear of house, Left/right side of house, Le
Right ide f building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, N� n
use only the tab
key to move your ress
cursor-do not MA
use the return 16 key. CRy/I own State Zip Code
2. System Owner:
ray
M re(
Na e
rertm
Address(if different from location)
MA
City/Town State i Code
,)F/-
Telephone Number
B. Pumping Record
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 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:
LS Lowell Waste Water +
Signature of Hauler Date