HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 3/10/2022 (3) Commonwealth of Massachusetts �EcEtvel-
City/Town of R 1 2022
System Pumping Record EA`TNpRTH Atoo\jE
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Form 4 Tp Nof DEPARTMENT
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/Rig ar oUh9usa, Left/right side of house, Left
Right side of building, Left/Right front of building, L /Right rear cy building, Under deck
on the computer, 1
use only the tab l� I
key to move your Address •�1� /(�
use the
return
not fg�V`, ��o MA
use the return
key. Cityfrown State Zip Code
2. S stem Owner:
Name
Address(if different from location)
MA
Cityrrown State Zip Code
- v
Telep� io a umber
B. Pumping Record
1. Date of Pumping 9'����� 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) el� 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 component pump
-Fiq ` - �o 0(d—
e k S c,r v ,-1 A4&L c3�6S er) 45 p4,4" i w
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo tion here contents were disposed:
6GLS Lowell Waste Water
Signature of Hauler Date