HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 CEDAR LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
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 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 Ight ear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, / Right rear of building, Under deck
on the computer, /�_
use only the tab �� G ink
key to move your Ad r ss
cursor- not �u W - MA C� LK
use the return
urn City/Town/Town
key. y State Zip Code
VQ 2. System Owner:
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Name
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Address(if different from location)
MA
City/Town State Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping s ZZ' 2. Quantity Pumped: is
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 condition of�omponent pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. c � n where contents were disposed:
GLSD Lowell Waste Water
dif Z _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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