HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 SUMMER STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
j system Pumping Record 0 03101
` Form 4 )V�'
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 hous Left/ lght rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of buil Ing, Left/Right rear of building, Under deck
on the computer,
use only the tab LIZ� _';�4(Y)mQ-- s
key to move your Addresscur i --
use the
- not k \ 80y� MA
use the return City/Town key. y State Zip Code
2. S stem Owner:
tab
Name
mtun
Address(if different from location)
_ MA
City/Town State Zip Code
OP -'�5 3s�
Telephone Number
B. Pumping Record
1. Date of Pumping Date L 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 conditio of component umped:
6. System Pumped By:
David Tined Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. gLaQation where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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