HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 878 WINTER STREET 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 maybe bsed, 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. System Location: Left ' front o 'ouse, Left/Right rear of house, Left/right side of house, Left
Rig ,side of buildin eft/ ght ront o building, Left/Right rear of building, Under deck
on the computer,
use only the tab V z4/ �.�.,,
key to move your Addleqs� "f�CJ __ _
cursor-do not RV
//IIIIVVl7 MA � "
use the return key. City/Town State Zip Code
2. System Owner:
Name
Bam
Address(if different from location)
MA
Cityrrown State (oU6 &31 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 00
Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grea.$e Trap
El Other(describe): \ —
4. Effluent Tee Filter present? ❑ Yesk No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
s
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. bLSD
here contents were disposed:
Lowell Waste Water
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Signature of Hauler Date