HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 TUCKER FARM ROAD 7/3/2023 :AN- Commonwealth of Massachusetts
City/Town of
j System Pumping Record
Form 4 �U1. g 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.thls 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/ ight ear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, Le /Right rear of building, Under deck
on the computer, -T ((��
use only the tab I SIC Q� 1 ck r M --
key to move your Address
cursor- not �iN^�u��er MA _ K
use the retet not
Cit !Town
key. y State Zip Code
„a
2. S stem Owner:
O �Z
Name
serum
Address(if different from location)
MA
City/Town State q Zip Code
P- -� - - I q
Telephone Number
B. Pumping Record
1. Date of Pumping Date
2. Quantity Pumped:
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 f component pumped:
OOL Mc�
6 System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
LSD Lowell Waste Water Ir
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1