HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 EVERGREEN DRIVE 5/10/2022 �ECEIVE�
Commonwealth of Massachusetts
City/Town of MAy 1 p 2022
System Pumping Record ;;wN of NO�PAR ME TES
Form 4 HEALTH I
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, Lefty ghFt`t rear of housl3 eft/right side of house, Left
Right side of building, Left/ Right front of building, Leff/Rlghfrear of building, Under deck
on the computer, l
use only the tab _ v-e
key to move your Address
cursor-do not
use the return — MA
key. City/Town State Zip Code
2. System Owner: fol (A
Name
iaen
Address(if different from location)
MA
City/Town State / Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping cf 2 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) C5 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 7No If yes,-was cleaned? ❑ Yes ❑ No
5. Observed condition of�mponent pumped:l f
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc n where contents were disposed:
GL 3 Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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