HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 386 SHARPNERS POND ROAD 5/8/2023 v
: Commonwealth of Massachusetts
City/Town of 'V3
system Pumping Record MPS ���PN
Form 4 �o�NO�
V
Ho�QPR�M
EPP
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 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/ i ht side of hou Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Un er eck
on the computer, 3S7� W`n0c,"S 9\
use only the tab G
key to move your Address
curuse the
return
not jd�Je� _ MA
use the return itylrown State Zip Code
key.
2. Syste Owner:
�t6'
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z --- -- 2. Quantity Pumped: Gallo
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:
A)o(-MAICI
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company -- — - -—
7. nfion where contents were disposed:
Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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