HomeMy WebLinkAbout- Septic Pumping Slip - 52 BANNAN DRIVE 5/3/2022 : Commonwealth of Massachusetts
City/Town of
System Pumping Record •. MAy 0 3 2022
Form 4 �1vTl�ANDO�EP,
C.3WN OF . DEPARTMENT
H
DEP has provided this form for use-by local Boards of Health. Other�b�rms 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/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, � :a �j,J ^ Am ; ^x I��
use only the tab !/q Amu (J
key to move your Addre� o ss��� / (�
cursor-do not 1 MA
key. n/
use the return City/I owwnn�'�'� 6 State Zip Code
2. System Owner:
Sr�6-0 t�s
Name
ienm
Address(if different from location)
MA
City/Town State � � Zip Cope
Telephone Number (off
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease 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. cation inhere contents were disposed:
GLSD Lowell Waste Water 42
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Z
Signature of Hauler Date