HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 FARNUM STREET 7/6/2022 RECENEC
: Commonwealth of Massachusetts
City/Town of JUL p 6 2022
y p g T ; ;ii OF j4OR ANDO\JF
- VI
S stem P�um in Record
Form 4 E; _TH DEPARTMENT
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/dig t rear o ouse, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab _ r��=►"Gi,�l/LLILvI _ � �'1�/'� y-f1/
key to move your Address
cursor-do not MA
use the return Ci /Town
key. tY State Zip Code
2. System Owner:
m5 !� r t.
Name
Isom
Address(if different from location)
MA
City/Town State Zip Code
77 v_(_ �aL�
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 70 0�
Date Gallons
3. Component: ❑ Cesspool(s) Q'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [2' No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
I
7. Location where contents were disposed:
SD Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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