HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 365 BOSTON 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 forrrl 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/Right front of house, Left/Right rear of house, Left./right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, '/_ Q /R _ C�use only the tab (,Qj cJ�(,J'�'lJ
key to move your dress
cursor-do not �� MA
use the return key. City/Town State Zip Code
2. System Owner:
�— � Name
Bnn �
Address(if different from location)
MA
Cityrrown State (/� Zip Code
1 ���-
Telephone Number
B. Pumping Record n
1. Date of Pumping Date - - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank El Grease Trap
El Other(describe): --�� 11
4. Effluent Tee Filter present?-�Yes ❑ No If yes, was it cleaned? es ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney_ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Lo where contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date