HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 WINDKIST FARM ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record �U` 0 3 z023
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®RIghfront of house, Left/Right rear of house, Left/right side of house, LeftRight side of building, ight front of building, Left/ Right rear of building, Under deck
on the computer,
use only the tab
key to move your Address
cursor- not �}, MA
use the return
urn Ci !Town -
key. y State Zip Code
2. System Owner:
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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 Z2-�z 2. Quantity Pumped: /
Date 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 condi ion of component pumped:
6. System Pumped By:
David T_iney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7, CGLSD6)
ion
where contents were disposed:
Lowell Waste Water
Signature of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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