HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 BOXFORD STREET 4/19/2022 Commonwealth of MassachusettsEc��v�c
City[Town of APR 1 g 2022
System Pumping Record RTH ANpovEK
Form 4 TOWE�TH DEPARTMENT
H
DEP has provided this form for use-by focal 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 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 housd Le Rig ear'of housa`Left/right side of house, Left/
Right side of building, Left/Right front of >�ildirig, Left/f fit rear of building, Under d ck
on the computer, ct
use only the tab U
key to move your Address
cursor-do not r MA
use the return key. City/Town State Zip Code
2
2. System Owner:
Name
�cem
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 —
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 comp?nent pump d: i
�P 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 Hauler Date ,
Signature of Receiving Facility(or attach facility receipt) Date
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