HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 7/3/2023 Commonwealth of Massachusetts
City/Town of
j 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, Le /Righ rear 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 l r l� `J
key to move your Address —
cursor-do not P , P �aUer MA C
use the return City/Town key. y State Zip Code
2. System Owner:
reb
Name
�n
Address(if different from location)
MA _
City/Town State Zip Code
a3i�g_ ssc- Nn
Telephone Number
B. Pumping Record
1. Date of Pumping pat 2. Quantity Pumped: Gallons�
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present?XYes 0 No If yes, was it cleaned? Yes ❑ No
5. Observed cond*tion of component pumped:
- G Jbur 4 �__-
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. ion where contents were disposed.
GLSD) Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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