HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 163 SUMMER STREET 4/19/2022 I
Commonwealth of Massachusetts
City/Town of APR 191W
System Pumping Record O�NoRYH AN�vEa
Form 4 TMENT
TOwN
fiM QEPAR
DEP has provided this form for use-by local Boards of Health. Other forms may beused,but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of hou ew - ig ear of house, /right side of house, Left 1
Right side of building, Left/Right front of bbli irig, Left/ g t rear o building, Under de
on the computer, 1
use only the tab t_ i,� -� f/�� ' �}
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
ra
Name -- -
Address(if different from location)
MA
City/Town State Zip Code
CC, - ( a �77
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped: C � —
Date 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:
v �
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 Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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