HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 LOST POND LANE 7/3/2023 : Commonwealth of Massachusetts
City/Town of
System Pumping Record ,U� 032023
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/ Right rear of hoesQbumg,
right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of Under deck
on the computer,
use only the tab ��� C 1� _
key to move your Addre s
cursor-do not MA
use the return
key. city/TownState Zip Ode
r� 2. System Owner:
Name
mxm
Address(if different from location)
MA
Cityrrown State Zip Code
01
Telephone Number
B. Pumping Record
1. Date of Pumping D �ath 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 conditio of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ticn where contents were disposed:
LSD Lowell Waste Water
130
Signature of Rauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Pade 1 of 1