HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 61 ESSEX STREET 5/20/2022 Commonwealth of Massachusetts RECENE�'
City/Town of o TV
2
system Pumping Record MAy f N'tA �
Form 4 101N 0tHpEPARTM�N�
HEA
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]R rear o�l=sp, Left/right side of house, Left
Right d of uiidin , Left/Right front of build' �g, Left g rear of building, Under deck
on the computer,
use only the tab
key to move your Adfrqss !
cursor-do not
A-YOX A��
key. MA
use the return Cityrrown State Zip Code
2. S tem Owner:
VQ
,S
Name
ienm i
Address(if different from location)
MA
City/Town State � Cod
Teleph a Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney _ _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locati ere contents were disposed:
SD Lowell Waste Water
Signature of Hauler Date