HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 JOHNNY CAKE STREET 7/3/2023 :_ Commonwealth of Massachusetts
City/Town of
a 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 Locat' Right front of house, Left/Right rear of hoes. Left fight side of house, Left/
Right side of bu tLeft/ Right front of building, Left/Right rear of bui ding, Under deck
on the computer,
use only the tab 2�l �X�rlll�i/ Cc��e
key to move your Address
cursor- not f\` C� � _ MA
use the return
urn Cit /Town
key. y State Zip Code
2. System O ner:
Name /
ietum
Address(if different from location)
MA _
City/Town State Zip Code
`t _�y _t� )`l GS-S
Telephone Number
B. Pumping Record
1. Date of Pumping 45—k-3 2. Quantity Pumped: ll -
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes V 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. tion where contents were disposed:
r
Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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