HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 26 STONECLEAVE ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
.i system Pumping Record o3tio�3
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 Right r ar of house, Left./ri ouse, Left/
Right side of building, Left/ Right front of building, e /Right rear of build'fn Under dec
on the computer,
use only the tab c_ _ c m tc,e-, LR- \`
key to move your Address
cursor-do not N &(�6u-y' MA CE
use the return Cityftbwn State Zip Code
key.
2. Sy tem Owner:
)Cl�\
Name
Address(if different from location)
MA
City/Town State n /r Zip Code
c/ t 'q ICt-Cc %p
Telephone Number
B. Pumping Record
1. Date of Pumping Date / 123 2. Quantity Pumped: Gallon
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 conditon of component pumped:
�c
6. System Pumped By:
David Tiney _ Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS Lowell Waste Water
Signatur o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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