HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 260 BRADFORD STREET 2/27/2022 Commonwealth of Massachusetts
City/Town of e CLI101 ' oJ��:
System Pumping Record FE No4�NM�
Form 4 t0'\00 INOEP
DEP has provided this form for use.by local Boards of Health. Other fo ms 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 forrh 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/Ri ear of house, /right side of house, Left
Right side of building, Left/Right front of building, Left/Righ re wilding, Under deck
the computer,
use
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use only the tab i/c(
key to move your Ad Tess cursor-do not AV,t MA
use the return City/Town State Zip Code
key.
2. Sys em Owner:
Na
ream
Address(if different from location)
MA
Cityrrown State Zip Code
( 66 7
Telephone Number
B. Pumping Record _
1. Date of Pumping Date � Zi 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank ❑ Grea$e Trap
❑ Other(describe): - -� ---
4. Effluent Tee Filter present? ❑ Yes ❑ o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu;4ed:
r� �e vet
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD Lowell Waste Water
z
Signature of Ha a Date