HomeMy WebLinkAbout- Septic Pumping Slip - 230 FOREST STREET 3/10/2022 BEGEIVEC
Commonwealth of Massachusetts MAR 1 a 2022
City/Town of �ti ANpOVEfk
` System Pumping Record VO\NNOFNpEPARTMENT
HEp t.TH
Form 4
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 ight front house, Left/ Right rear of house, Left/right side of house, Left
Right side of building, Le fight front of building, Left/Right rear df building, Under deck
on the computer, 30
use only the tab
key to move your Addr�j�r
cursor-do not /`%� ` [J1yA MA l j
7
use the return d/
key. City/Town State Zip Code
2. System Owner:
Name
BMI Jj
Address(if different from location)
MA
City/Town State �. 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? ❑ Yeso If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
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