HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 2/27/2022 :�L\ Commonwealth of Massachusetts "�ECIA\X1,
City/Town of
b System Pumping Record
Form 4 7%A N�
WN Of NVAC
DEP has provided this form for use-by local Boards of Health. Other formy 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 forrh they use.The System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left/ rear of a, Left/right side of house, Left
Right side of buildin Left/Right front of buildiri , Left Rig rear f building, Under deck
on the computer,
use only the tab
key to move your Ad ess
cursor-do not (f e MA
key.
use the return ity/Town State Zip Code
2. S tem Owner:
Name
nttm
Address(if different from location)
MA
City/Town Stat Zip Code
Telep one Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date � Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grew Trap
❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component
Iumped:
c
6. System Pumped By: S .
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLS Lowell Waste Water
_ ��
Signature of Hauler Date