HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 TANGLEWOOD LANE 3/10/2022 �S�ewel)
: Commonwealth of Massachusetts
V. City[Town of MAR 1 p 2022
a
System Pumping Record NpR,N
o� T
A"ENt
Form 4 oEpAaM
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 fr f House, Left/Right rear of house, Left/right side of house, Left
Right side of building, Lei
e Right front building, Left/Right rear df building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not MA Dl x
use the return ow4 key. 'City/Town State Zip Code
2. System Owner:
&/qij9f
Name
renm
Address(if different from location)
_ MA
City/Town State�6 � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ' / 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 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 co m Went umped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number ?
Bateson Enterprises, Inc.
Company
7. Lo ' n where contents were disposed:
GLS } Lowell Waste Water
e7 a 1A1/,2 2 '
Signature of Hauler Date