HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CARLTON LANE 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 6 2022
System Pumping Record b
Form 4TC�NNHEALTH DEPARTMENTER
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
iocal 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 Locatlon:(t ep Righ ro t pf ou Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig t front of building, Left/Right rear df building, Under deck
on the computer, U
use only the tab I Q l G�f I �UV\ L✓` Aind4dXF-6(
key to move your Address
cursor-do not
use the return Ci frown _ MA
key. ty State Zip Code
2. System Owner:
raS
Name —
rram
Address(if different from location)
MA
City/Town State Zip Code
A TS ' 9-3 t 7
Telephone Number -
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: y
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [g No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD) Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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