HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 BRADFORD STREET 4/19/2022 RECEtUED
Commonwealth of Massachusetts
City/Town of ApR 19 2022
b System Pumping Record SOwNCFSOIR NDOVER
HEp,1.TH DEPAa? Nt
Form 4
DEP has provided this form for use-by local Boards of"Heaith. 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 t(
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Lg�g#front se, Left/Right rear of house, Left/right side of house, Left
Right side of buildinRigh front building, Left/Right rear of building, Under deck
on the computer,
he tab 41� /3&A 0 ) � t�use only the tab �J �tJ�ti
key to move your Address
cursor-do notrwm MA
use the return City/Town State Zip Code
key.
2. System Owner:
'Mp
B�
Address(if different from location)
_ MA
City/Town State /' „ p Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 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 p Vmp`ed:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo where contents were disposed:
LGLSD I Lowell Waste Water
Signature of Hauler Date