HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 FOREST STREET 2/27/2022 :�L\ Commonwealth of Massachusetts �C�����
City/Town of tit
b System Pumping Record FEe ti� No0,101
Form 4 NO����1010
NZ
DEP has provided this form for use.by local Boards of Health. Otherfo>r;4\1l ay 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 forrim 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/Rig house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Le /Right fron of bui ding, Left/Right rear of building, Under deck
on the computer, Y1
use only the tab ?
key to move your A dress /
cursor-do not u n ��^` MA ( �
use the return Q
key. ity/Town State Zip Code
2. S stem Owner:
Name
ream
Address(if different from location)
MA f�City/Town State 9Z" C d�
Telephone Number
B. Pumping Record / 11 5�6 6
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) it-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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. Lpzat*LQn where contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date