HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 ABBOTT STREET 5/10/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record •
MAY 1.�2022
Form 4 TOWN OF NOR.TVAR MAb' ENT R
H�LTH DEPA
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 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: Le to t 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, „ c J
use only the tab ">(? 7 t) T j�/�y /-e�
key to move your Address -
cursor-do not MA
use the return Ci /Town
key. tY State Zip Code
r�
2. System Owner:
aK�d
Name
aom
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date r ZSPPtic
2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition o component pumped:
ty V-1 ez
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Locat' where contents were disposed:
GLS Lowe Waste Water
Signature of Hau Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1