HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 455 CHESTNUT STREET 2/27/2022 :�L\ Commonwealth of Massachusetts 0.9PO"
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City/Town of ti�ltis 040\
System Pumping Record
Form 4 Sods�o�
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DEP has provided this form for use-by local Boards of Health. Other forms 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 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 se, Left/right side of house, Left
Right s e of build7ZJAI��
/ Right front of building, Left ght rear o building, Under deck
on the computer,use only the tab //! /
key to move your ore s
cursor-do not �J� MA
use the return A4�
key. Uty/Town State Zip Code
2. Sy to Owner:
r Name
Address(if different from location)
MA
City/Town State � ZRCode
Telephone Number �y 1
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) A� 5eptic 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 compog-eqt pumpe :
i
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
Signature of Hauler Date