HomeMy WebLinkAboutSeptic Pumping Slip - 767 JOHNSON STREET 7/13/2016 Commonwealth f Massachusetts
Cit�/Town of
YS
Form ( pg{t
DEP has provided this form for use=by local Boards of Health. Other forma r fay as l w ut the
information must be substantially the same as that provided here. Before using.thls ,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. Inf®r ti n
I. System Location: Left/Right front of house, Left/Right rear of house a F` a of hausg, eft 1
Right side of building, Left/Right front of building, Left/Right rear of'66N ding, n`der dec�li
Address
KJ
Cityfrown State Zip Code
2. System Owner,
Name
Address(if different from location)
City/Town ' State p Code
Telephone Number �w
13. Pumping Rpcord .
1. Date of Pumping Date 2. Q entity Pumped:
Gallons
3. Type-of system: ® Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System
6; System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Logfi here contents were disposed:
Lowell Waste Water
1.
Sign a Haule Date
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