HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 128 MILL ROAD 8/29/2022 RECE�vED
Commonwealth of Massachusetts AEG 2 9 2022
City/Town of° pf 9 + OTN DEPAR ME TER
System Pumping Record iO�EAL
Form 4
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 your
local Board of Health to determine the forrh they use. The,System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left i t fr t of , eft/Right rear of house, 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, cY
use only the tab 1 b _
key to move your Address
cursor-do not MA
use the return
key. Cityrrown State Zip Code
2. System Owner:
�0 U
Name
�n
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date— �� — 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
� t
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Loca where contents were disposed:
GL D Lowell Waste ter
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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