HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 95 CARLTON LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
i System Pumping Record �U` 032°23
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/ igh front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, L Right front of building, Left/Right rear of building, Under deck
on the computer, 9� C� I
use only the tab
key to move your Address
cursor-do not MA
use the return key. Cityrrown State Zip Code
2. System Owner.
teb i_
Name
ie�um
Address(if different from location)
MA
City/Town State Zip Code
22 Y-Ga - z-GO-
Telephone Number
B. Pumping Record �^
In
1. Date of Pumping Da e 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 of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
L Lowell Waste Water
?3 543
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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