HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 MILL ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record •
Form 4 JUL 0 3 2023
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 Righ front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, L ight front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab 1, 1
key to move your Address S_
cursor-do not
use the return City/Town key. y State Zip Code
2. System Owner.-
Name
ielum
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping co 4 2. Quantity Pumped: ��� --
Date 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 omponent pumped:
--------- 0m-f\.^ ----
6. System Pumped By:
David Tiney MasrF5821
Name Vehicle umber
Bateson Enterprises, Inc.
Company
7. Otion where contents were disposed:
Lowell Waste Water
co
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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