HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 149 MARIAN DRIVE 2/27/2022 0
: Commonwealth of Massachusetts
City/Town of �j vo-V ,
System Pumping Record F� No � �Nc
Form 4 �NOEPP
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 Inform' ation
1. System Location: Left/Right front of house, Left/Right rear a, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/ ght rear building, Under deck
on the computer, /V9 A
use only the tab G1 / �j' /q INS vt
key to move your Azz�&
MA
cursor-do not use the return
key. itylrown State Zip Code
2. System wner:
Name
rerun ,
Address(if different from location)
MA
Cityrrown Stat v �ode
TelJp_hon6 Number
B. Pumping Record
1. Date of Pumping pate Z� 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
ther(describe):
Al
:
4. Effluent Tee Filter present? ❑ Yes �LNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Lo where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date