HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 HAY MEADOW ROAD 2/27/2022 Commonwealth of Massachusetts
City/Town of �� tiolti
System Pumping Record e TH aN MENZ
Form 4 jo AOo kADspPaS
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/Right front of house, Left/Right r use, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left Right rear f building, Under deck
on the computer,
use only the tab 9 94-1
key to move your Address D���
cursor-do not MA
use the return key. ity/Town State Zip Code
2. S tem Owner:
ray
R 9467�
ame
rerun
Address(if different from location)
MA
City/Town St Zip Code
171) �� C S
Telephone Number
B. Pumping Record
1. Date of Pumping Oq
ate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
.,"-kOther (describe): 10 � 5
4. Effluent Tee Filter present? ❑ Yes *o 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. Loc ion where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date