HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 SUMMER STREET 5/20/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
- � b MAY 2 0 2022
System Pumping Record •.
Form 4 TOWN HEALTH DEPARTMENF NORTH T
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 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 Infort'ation
1. System Location: Left/Right front of house, Left/Right r s, Left/right side of house, Left
Right sl a of building, Left/Right front of building, Le /Right rear df)uilding, Under deck
on the computer, \
use only the tab u �J.�,
key to move your Ad�/ti G%^c� ��'
cursor-do not � CQ� MA
use the return key. City/Town State Zip Code
2. Sy tem Owner:
ray
y'U
Name
rend
Address(if different from location)
MA
CitylTown State )�711 �ip 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): —
�a
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
1 Wpg'�
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. cation here contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date