HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 152 MILL ROAD 7/3/2023 :-C-\ Commonwealth of Massachusetts
City/Town of
�j system Pumping Record �` o32p23
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may '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 ont of house, Left/ Right rear of house, Left/right side of house, Left/
Right side of building, l-e fight front of building, Left/Right rear of building, Under deck
e
on the computer,
use only the tab
key to move your Address `
cursor- not � IanCoU� _ MA
use the return
urn key. City/Town State Zip Code
2. System Owner:
teb
Name
mrun
Address(if different from location)
MA
City/Town State Zip Code
1041
Telephone Number
B. Pumping Record `
1�1 lZ..s IStiU _
1. Date of Pumping pate -- - 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 condition of component pumped:
PO�-rv-"A
6 System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ntion where contents were disposed:
Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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