HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 7/3/2023 : Commonwealth of Massachusetts
City/Town of
j System Pumping Record 10
JUL o 3 2023
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 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 hou e, Lef>/, L
fight rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of ' eft/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Address
cursor- not 4�� MA
use the return
urn key. Cityfrown State Zip Code
2. System Owner:
Name
mnm
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — 2. Quantity Pumped: ---
Datt e Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - --- ---- ----
4. Effluent Tee Filter presen/ponent
Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of co pumped: /-
6. System Pumped By:
David Tiney MrssF5821
Name Vehi Lice umber
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
(Gncn
Lowell Waste Water
ro IV
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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