HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 BANNAN 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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/ t front e, Left/Right rear of house, Left/right side of house, Left
Right side of building(Left/ ig front of b ildirig, Left/Right rear of building, Under deck
on the computer, �X2 k „ 1 n n I'q'V CW1,L�_
use only the tab (� /'(//(J _
key to move your Addres
cursor-do not MA /G
use the return `'yfJ ✓fv" �� 0 O
key. CityTTown State Zip Code
2. SV2. S s em Owner:
I.C(2 ku
Name
snm
Address(if different from location)
MA
CitylTown Stet la
, Q< 66ip ode
S r—
Telephone Number
B. Pumping Record
1. Date of Pumping Date � � 2. Quantity Pumped: S�
Gallons
3. Component: ❑ Cesspool(s) et<zeptic Tank ❑ Tight Tank ❑ Grease 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. Locati n where contents were disposed:
SD Lowell Waste Water
Signature of Hauler Date