HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 215 FOREST STREET 7/3/2023 Commonwealth of Massachusetts
u
City/Town of
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. Faci-lity Information
1, System Location: Left/Right front of house, Left Righ ear 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, c r 1
use only the tab L t 1'bre S S
key to move your Address
cursor-do not -Ps(\ ver MA
use the return --
key. Ci y/Town State Zip Code
2. System Owner: 1
Name — -- -- -
uun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: /b
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. Observled1conditio of component pumped:
6. System Pumped By:
David T_in_ey Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. oc 'on where contents were disposed:
GLSD Lowell Waste Water
Signatuee-11 Rauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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