HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 3/10/2022 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
- b System ping� Pumping Record .. MAR 10 2022
Form 4 TO\NN NoF NORTH TH pEPARTMER
ENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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/RI ar se, Left/right side of house, Left
Right side of building, Left/ Right front ofbuilding, ft/Right rear f building, Under deck
on the computer, �� /ly, /�
use only the tab r—j(SZ '` l�.(„ !�-!�`�� `''`_
key to move your Address /�
cursor-do not �,p/ MA
use the return CiF'��w'n "" �� State Zip
key. p
,n
2. System Owner:
Name
�enm
Address(if different from location)
_ MA
City/'Town State Zip Code
�s - /dam Telephone Number
B. Pumping Record
1. Date of Pumping �- Quantity Pumped: /�6c1
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): -- -- - -
4. Effluent Tee Filter present? ❑ Yes E -` If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone mped:
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