HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 SHERWOOD DRIVE 4/19/2022 Commonwealth of Massachusetts RECEIVED
City/Town of APR 19 2022
System Pumping Record •
N OF NORTH ANDC
Form 4 TO HEALTH DEPARTMENT'
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 yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right ouse, Left/Right rear of house, Left/right side of house, Lei
Right side of b iding, Le Right front o building, Left/Right rear of building, Under deck
on the computer, 9�
use only the tab
key to move your Address f� yq
cursor return
not ���f/�/G&G�c�'L- MA
use the return
key. City/Town State Zip Code
2. S em Owner:
0_5 _
ame
rertm
Address(if different from location)
MA
City/Town State � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gall
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Y4--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. Location where contents were disposed:
GL D Lowell Waste WatK
j- 3 �
Signature of Hauler Date