HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 BOSTON STREET 7/17/2023 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 forms,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 Eght ar of house, Left/right side of house, Left/
Right side of building, Left/ Right front of buildin ght rear of building, Under deck
on the computer,
use only the tab S`
key to move your Address
cursor- not N ^ � MA
use the return
urn Cit !Town `
key. y State Zip Code
2. System Owner:
—s \nc4 1 '
Name - - -
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
Z� 1
1. Date of Pumping pate - _ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes El No If yes, was it cleaned? [� Yes ❑ No
5. Observed condition of co onent pumped:
Pa P-4— -_-_ —_
6 System Pumped By: /�
David Tiney Mass F5821 �"�
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD Lowell Waste Water
Signature of qauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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