HomeMy WebLinkAboutSeptic Pumping Slip - 940 JOHNSON STREET 5/17/2012 Commonwealth Ith Of Massachusetts
City/Town of
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System Pumping Record
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Form 4 a ti�'��v+a UF i K) M N:)OVE
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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 house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address /
City/Town State Zip Code
2. System Owner: ( m`
Name
Address(if different from location)
City/Town Stat -- Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: dons
3. Type of system: e t Tank
El Tight Tank
Q-�other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi of Sys m:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
1 C
Sign toe Haule Date
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