HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 981 JOHNSON STREET 5/8/2023 Commonwealth of Massachusetts ¢����•���
City/Town of os
.i System Pumping Record .� 09,% No04S
Form 4 MO N��QPP�M�N
DEP has provided this form for use-by local Boards of Health. Other fo4j*kiy 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 form 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/ Right front of house, Left/Right rear of house, Left/righ side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, nder deck
on the computer, Rc 1
use only the tab 6 �O
key to move your Ad res
cursor-do not MA _
use the return ` S
key. City/Town State Zip Code
2. System Owner-
tab
tt
,
Name
Address(if different from location)
MA
City/Town State Zip Code
GOD" 119C., ct 10 Z
Telephone Number
B. Pumping Record
1. Date of Pumping Date 3I 2. Quantity Pumped: Galls
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:
6. System Pumped By:
David Tin_ey_ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. rL tion where contents were disposed:
Lowell Waste Water
Si nat re of Hauler
g Date—
Signature of Receiving Facility(or attach facility receipt) Date
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