HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 455 CHESTNUT STREET 2/27/2022 Commonwealth of Massachusetts
City/Town of
system Pumping Record
Form 4 F� iN PNo N�
DEP has provided this form for use-by local Boards of Health. Other f p y e 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 t<
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, Yeft/ Right front building, Left/Right rear of building, Under deck
on the computer, his ✓, ) L
use only the tab V -7
key to move your Address , I �A& xg�
cursor-do not �,/JV� /ry�..-A(TJ'i G// _ MA
use the return key. City/Town State Zip Code
2. S stem Ow�ngr: /144 C
i� ame - -
f min
Address(if different from location)
MA
Citylrown State ��— � Zi Code C/
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tankl� El Grease Trap
at!❑ Other (describe): h.- � ��v' Le_�4- a�
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc ion where contents were disposed:
GL Lowell Waste Water
Signature of Hauler Date