HomeMy WebLinkAboutSeptic Pumping Slip - 940 JOHNSON STREET 5/17/2016 Commonwealth u
Pumping.City/Town of
YS
r '� `` � A
Form 4
' J'G;:�V'I�'it � Ca��..
DEP has provided this form for use4by local Boards of Health. Other forms my�6�e�`tlsed, 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 a Righi ikqf house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
ty .
�p State g Cody
Telephone Number
B. /
Pumping ec®r �
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ®des ® ..m...
No If yes, was it cleaned? ❑des® No
5. Condition of Syste
r
V\'c)w
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location here contents were disposed:
G L S. Lowell Waste Water
&jr4 Sign t e Haule Date
t5form4.doc>06/03 System Pumping Record•Page 1 of 1