HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 193 BOXFORD STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
t system Pumping Record 10 I1J . 0 3 2023
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/Right front of house, Left
Righ rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building,,Right rear of building, Under deck
on the computer,use only the tab I cis S� _
key to move your A dr ss
cursor-do not MA 41
use the return SM
key. City/Town State Zip Code
2. System Owner: tt
Name
rerun
Address(if different from location)
MA
City/Town State ` GZip Code
Telephone Number
B. Pumping Record
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 condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
LSD Lowell Waste Water
U- IZ
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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