HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 RALEIGH TAVERN LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
j System Pumping Record o3tip23
Form 4 �V1.
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 hous Left�Fight rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of bul g, Left/ Right rear of building, Under deck
on the computer,
use only the tab
key to move your Addrs
cursor- not
use the return - -- -- - — MA — - — d IR t�
key. City/Town State Zip Code
ee 2. System Owner:
Name
serum
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons
2. Quantity Pumped: /
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:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. L ion where contents were disposed:
LSD Lowell Waste Water
2Z Z�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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