HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 SUGARCANE LANE 5/10/2022 �ECEtVED
: Commonwealth of Massachusefts
City/Town of Mpy 10 2022
System P�um in Record rH A"DOER
pEPAR
Form 4 p g jOHE�TH TMENT
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 forrh 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(/RigTt front of house;Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab r,
key to move your Address
cursor-do not MA
use the return City/Town key. tY State Zip Code
2. System Owner:
reS
01�
Name
cram
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ��- ?�2. Quantity Pumped: Gallons
S( �l
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [� No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumT
ed:
0f V"' ' ( T—'e
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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