HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
.j System Pumping Record 0 jv
Form 4 J
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 ear of house, Left/right side of house, Left f
Right side of building, Left/ Right front of buildirig, Right rear of building, Under deck
on the computer, c?/
use only the tab (b if(\ck fh —
key to move your Address
cursor- not W, R�c�o�,e� MA
use the return
urn key. City/Town State Zip Code
t� 2. System Owner:
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Name
stun
Address(if different from location)
MA
City/Town State 1 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date -- 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 conditi n of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. tion 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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