HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 719 JOHNSON STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
i System Pumping Record 10
U` 0 3 2023
Form 4 1
DEP has provided this form for use-by local Boards of Health. Other forms may beused, 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/Right rear of house, Left right s e of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, nder deck
on the computer,
use only the tab
key to move your A sscursor-do not —use the return key. Cjde
MA dl
own State Zip Code
2. System Own
Name _ -
Address(if different from location)
j MA _
City/Town State q G Zip Code
Telephone Number
B. Pumping Record
/5-12-
1. Date of Pumping 2. Quantity Pumped:
Date 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 condi 'on of component p mped:
6. System Pumped By:
David Tined Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
tGLS0 Lowell Waste Water
5
Signatur of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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