HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 WINTERGREEN DRIVE 5/10/2022 V SSr O
: Commonwealth of Massachusetts 1�202'l
City/Town of MAC
System Pumping Record NOFNO l"R MEN"
Form 4 SO NEP►-�H OE
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/Right rear of house, Left ht :of house. eft
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab _ ,( tl^ 10 do �[f�
key to move your Address
cursor-do not MA
use the return Ci frown
key. tY State Zip Code
2. System Owner:
r�5 \ 1
Name
item
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Ll ''�4 `)` 2. Quantity Pumped: t Soo
Date Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ENo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe
il
f 1�orw� C
6. System Pumped By:
Jon Kirmil _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Lo f where contents were disposed:
GLSD Lowell Waste Wat r
Signature of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1