HomeMy WebLinkAboutSeptic Pumping Slip - 795 JOHNSON STREET 8/1/2016 : Commonwealth of Massachusetts
City/Town of f t",
, � r;
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 form,check with your
local Board of Health to determine the form they use. Tile System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. lnfoirmlation
1. System Location: Left/Right front of douse, Leff/Right rear of house, Left I right side of house, Left/
Right side of building, Left 1 Right front of building, Left I Right rear of building, Under deck
Address 7ja
C"i
tyrrown '-f[ State f Zip Code
2. System Owner.
Name.
Address(if different from location)
City/Town State�� � Zip Cady ;
Telephone Number +"d
B. Pumping Ptecord
1. Date of Pumping pate 2. Quantity Pumped:
Gallons t�
.3. Type-of system: ❑ Cesspool(s) eptic Tanis ❑ Tight Tank t
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 rvo If yes, was it cleaned? ❑ Yes ❑ No
' S. Condition of.system: ��oa �
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
--- ---
Company
7. Loca' vh re contentsrwere disposed:
G L S. Lowell Waste Water
U Tr
cSA
SignAture I Hhule Date
t5form4.docr 06103 System Pumping Record•Page 1 of 1