HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
j system Pumping Record •
Form 4 ,U` 0 3 2023
DEP has provided this form for use-by local Boards of Health. Other forms may beused, 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/Right rear of house, Left AG h side of house, Left/
Right side of building, Left/ Right front of building, Left/ Right rear of building, Under deck
on the computer, 11� n �t a\�` ( qv�^ 1{t i
use only the tab � \� r "� �
key to move your Address
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use the return k l _ - --- -- -- V t 6-t
key. City`rTown State Zip Code
2. System Owner:
rib
Name --- -- --
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Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping s I�'11-3 2. Quantity Pumped: %SSG -
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — — - —
4. Effluent Tee Filter present? ❑ Yes m 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. L ion where contents were disposed:
LSD Lowell Waste Water
8
— - -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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