HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 426 SUMMER STREET 7/3/2023 ,&�N Commonwealth of Massachusetts
City/Town of o��oti3
j System Pumping Record
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 house, Left PeP
rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, Right rear of building, Under deck
on the computer, L(^ M s
use only the tab (,p (Y�
key to move your Add ess
cursor- not MA 01
use the return � - — - -- -
key. City/Town State Zip Code
2. System Owner:
k.M
Name
roam
Address(if different from location)
MA
Citylrown State Zip Code
�I
Telephone Nu�mber
B. Pumping Record
1. Date of Pumping Da e 3 2. Quantity Pumped. Gallo S?-)o
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 Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. oc ion where contents were disposed:
GLS Lowell Waste Water
aZ
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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