HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 4 CHRISTIAN WAY 5/20/2022 : Commonwealth of Massachusetts RECEIVED
City/Town of MAY 2 0 2022
System Pumping Record
Form 4 TOWN OF NORTH F~
HEALTH DEPART-FMENTMENT
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 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 Locationz_Led/Rigt4 front of houseXeft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rigght front of building, Left/Right rear of building, Under deck
on the computer, C 1 cite),��1, IMA
use only the tab {key to move your Address
cursor-do not
use the return Ci /Town --
key. ty State Zip Code
2. System Owner:
Name
ream
Address(if different from location)
MA
Cityrrown State Zip Code
`( 7 - `P U
Telephone Number '
B. Pumping Record
1. Date of Pumping CO 2. Quantity Pumped: l�
Date Gallons
3. Component: ❑ Cesspool(s) Imo' Septic Tank ❑ Tight Tank
g El Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes 46 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c mponent pumped:
—- Vw R
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
5' I! o a
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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