HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 WINDKIST FARM ROAD 2/27/2022 : Commonwealth of Massachusetts �ecvoe'o
City/Town of �I'Loti�-
system Pumping Record FEe oo`'�
Form 4 o f t po P0�0
=.ON1N �N�E
DEP has provided this form for use-by local Boards of Health. Other forrrrd�'� 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 re use, Left/right side of house, Left
Right side of building, Left/Right front of building, Left ght rear f building, Under deck
on the computer, 0)�N D �' .�— j/�� T—
use only the tab O- �� �*d/�in
key to move your A Tess O l ,,1
cursor-do not MA
use the return trityrTown State Zip Code
key.
2. Syst m Owner:
ray
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Name
rerun ��
Address(if different from location)
MA _
Cityrrown State Zip Code
l
0 �A�7
Telephone Number
B. Pumping Record IYIN
1. Date of Pumping ate 2. Quantity Pumped: Gallons_
3. Component: ❑ Cesspool(s) 4Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ElNo If yes, was it cleaned? Yes ❑ No
1
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Lowell Waste Water oe
Signature of Hauler Date