HomeMy WebLinkAboutSeptic Pumping Slip - 1000 JOHNSON STREET 8/5/2016 Commonwealth of RECEIVED
CVTown of
System Pumping-Record
"
Form 4 OWN OF NU C a u X',�DOVER
DEP has provided this farm 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 Mouse, Left r;ht of haul , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left ght rear of building, Under deck
Address y ,
citylrown Sfate Zip Code
2. System Owner.
Name
Address(if different from location)
cityfrown State /
.
Telephone Number
t
a
i•
.B. Pq mping kocord
1. Date of Pumping bate 2. Quantity Pumped:
Gallons `
3. Type-of system: ❑ Cesspool(s) ❑° eptic Tank ❑ Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No,
5, Condition of System: (
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
company
7. Location--wiere contents were disposed:
ISIgn AHaule Lowell Waste Water
Date
t5f6rm4.doc 06/03 System Pumping Record•Page 1 of 1