HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1260 SALEM STREET 5/31/2022 Commonwealth of Massachusetts
City/Town of 1011-
3
System Pumping Record
Form 4 �NOFNpEPN
10 NEP��N
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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/,Right front of House Left/Right rear of house, Left/right side of house, Left
Right side of building, LWT Righht fron—t o-buiidirig, Left/Right rear of building, Under deck
on the computer, O
use only the tab C e_
key to move your Address /
cursor-do not A� , �l�tCl()rh� MA G (Yy'S
use the return Ci /To n
key. �' State Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
MA
City/Town State Zip Code
`/-717
Telephone Number
B. Pumping Record
1. Date of Pumping 5- 7&/Z Z 2. Quantity Pumped: 1 5 6 C)
Date Gallons
3. Component: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes P"No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
N�I-rA CIL(
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Lo tion where contents were disposed:
LSD Lowell Waste Water
Signature Hauer
Signature of Receiving Facility(or attach facility receipt) Date
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