HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 SUMMER STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
.z 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 forms, 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 Inforrhation
1. System Location: Left/Right front of house, Left/Right rear of house, Left 0, er
de of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of buildin deck
on the computer,
use only the tab ��1 s,M M 2..r
key to move your Ad ress
cursor-do not N � MA
use the return key. City/Town State Zip Code
2. System Owner:(
I I c cr_ C•C C't O S
Name - -
rnun
Address(if different from location)
MA
City/Town State Zi Code
9__
Telephone Number
B. Pumping Record rat
6
1. Date of Pumping bate
2. Quantity Pumped: Garton
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 condition of component p mped:
__ I w f an+ -_ — - ---
6. System Pumped By:
David T_in_ey Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. non where contents were disposed:
Lowell Waste Water
S 3 3
Signature of FTauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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