HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 EQUESTRIAN DRIVE 3/10/2022 : Commonwealth of Massachusetts "
City/Town of
- MAR 102022
System Pumping Record •.
Form 4 TOWN OF pE R
ARTMENT
HEALTH
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 forrh they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/R1 se, Left/Right rear of house, Left./right side of house, Left
Right side of building, L /�frontuildirig, Left/Right rear of building, Under deck
on the computer, Z�;
use only the tab
key to move your Address
/
cursor-do not rg MA G l Sys
use the return
key. ity own State Zip Code
��
2. System Owner:
Name
rerun
Address(if different from location)
MA
City town State Zip Code
95/-- '�2� o�
Telephone Number
B. Pumping Record r�pp
'?
1. Date of Pumping 2. QuantityPumped:» ' Date r Ga ons
3. Component: ❑ Cesspool(s) *Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes No 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:
�LSDLowell Waste Water
- y,)z
Signature of Hauler Date