HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1514 SALEM STREET 4/19/2022 Commonwealth of Massachusetts
City/Town of QpR 1 g ti022
System Pumping Record Noa1H ANM�°;�
Form 4 ,To HE oTN 1DVN
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: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building,
pLeft
�' i ht front o uildirig, Left/Right rear of building, Under deck
on the computer,use only the tab
key to move your Address
cursor-do not o-) r'71 MA
use the return key. City/Town State Zip Code
,c
2. Sy emlOwner:
Name
IBOYl1
Address(if different from location)
MA
City/Town Stye„ 9� Zip Code
Telephone Number
B. Pumping Record / J
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspo s Septic Tank ❑ Tight Tank ❑ Greage Trap
lv lS �� S �
Other(describe): K —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. LocgliQn where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date