HomeMy WebLinkAboutSeptic Pumping Slip - 851 JOHNSON STREET 6/24/2016 ssachusetts
Commonwealth of Ma
r. M I wn of .
W' �
• t i r
�ai�� .
`..
Form 4 HEAL Ii
P.P
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the
information must be substantially the tame 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 Mous e 1 R ` "" .W. r
ft..J-t�igh��"r�tr'f haus�", Left/right side of house, Left/
Right side of building, Left/Right front of bul ring, Left/Right rea f building, Under deck
Address
....✓ � i.e`a �„w�� Y � ',.h .._ /'.. � 1 r^Y" ux,inl Nq...w
City/Town State Zip Code W^
2. system Owner.
Name'
Address(if different from location)
City/Town State Zip Code
Telephone umber
p
Tele N t.
i
. Pumpin ec r u
Date Gallon
1. Date of Pumping 2. Quantity Pumped ---,`
3. Type-of system: ❑ Cesspool(s) ' ❑. Ic"Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee f=ilter present? ❑ Yes ❑_�o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
° (V
6: System Pumped By:
Neil.Batesbn P5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
IS Lowell Waste Water
SIgnAHaule Date
t5form4.doo-06/03 System Pumping Record Page 9 of 1