HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 7/3/2023 : Commonwealth of Massachusetts
City/Town of
j system Pumping Record 10
03 JW
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 QRjgfront of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, ight front of building, Left/Right rear of building, Under deck
on the computer, `��
use only the tab
key to move your Address
cursor- not la-n c�l� MA _ �l V6'(
use the retet not
key. City/Town State Zip Code
2. System Owner:
tab
`t �e
Name
ie�um
Address(if different from location)
MA
City/Town State Zip Code
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. Observe d condition of component pumped:
rrf:t led
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. nation where contents were disposed:
Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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