HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 GRAY STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
.z System Pumping Record �u` 031023
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 Rng.,�Left
Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of bull / Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return Ci frown
key. y State Zip Code
2. System Owner:
Name - ----
mun
Address(if different from location)
MA
City/Town State U LA Zip Co/de
Telephone Number
B. Pumping Record
1. Date of Pumping �Z3 2 Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —
4. Effluent Tee Filter present? ❑ Ye/Umped:
No If yes, was it cleaned? ❑ Yes [I No
5. Observed condition of component
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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