HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 CARLTON LANE 5/20/2022 Commonwealth of Massachusetts REGEtvEo
City/Town of MAY 2 p 2022
j System Pumping Record VviANpovER
Form 4 TOWN OTH pEPA TMENT
HE
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 wlth 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/ rear of a, Left/right side of house, Left
Right side of building, L ft/Right front of buildi , Left/ g rear " building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not MA O% �
use the return key. City/Town State Zip Code
2. System Owner:
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Name
rerun
Address(if different from location)
MA
Cityrrown State ip ode
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Telephone Number
B. Pumping Record
1 foci
1. Date of Pumping Date S-9-22-- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Greage Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
WO K 1A1
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. 1-9patikN4,,where contents were disposed:
GLSD Lowell Waste Water g
/_ 0D
Signature of Hauler Date