HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1171 TURNPIKE STREET 3/10/2022 qeP
Commonwealth of Massachusetts
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City/Town of AR ���� oo,E1
system Pumping Record
Form 4 o`►'I ��N
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DEP has provided this form for use.by local Boards of Health. Other forms maybe 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 t(
the local Board of Health or other approving authority.
A. Facility Information
1, Location: Left/Right front of house, Left/Right rear of house, Left./right side of house, Left
Right side b,f building, Left! Right front of building, Left/Right rear of building, Under deck
on the computer, /jf�"7j ✓��/g -'7—_—
use only the tab / / /� /"
key to move your Addr ss //
cursor-do not �` _ MA /�j
use the return City/Town State Zip Code
key.
2. System
Owner:
r' Name
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Address(if different from location)
MA
City/Town State Zi Code
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Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Ces pools) Septic Tank ❑ Tight Tank ElGrea$e Trap
Other(describe):Iq
4. Effluent Tee Filter present? ❑ Yeses No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen,(pumped:
6. System Pumped By:
David Tiney — Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo n where contents were disposed:
GL Lowell Waste Water
Signature of Hauler Date