HomeMy WebLinkAboutSeptic Pumping Slip - 544 JOHNSON STREET 8/9/2016 Commonwealth of Massachusetts
City/Town of .
M. C io
System P'�umping-Record AUG
Form 4
DEP has provided this form for use=by local Boards of Health. other 6691069yb" ad, 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/ ght'rear of hous: , Left/right side of house, Left/
Right side of building, Left/Right front of building, of tlklghtmar of building, Under deck
Address
Citylrown State Zip Code
2. System Owner:
Name`
Address(if different from location)
CitylTown ` State `•�., s Zip ;
f ' e
Telephone Number ` .
.B. Pumping.Ropcord
1. Date of Pumping IS Z Quantity Pumped: Gallons r�'
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem:
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' n where contents-were disposed:
G L S: Lowell Waste Water
aJA " i' .►-�---.. C � ( .
Sign a qf HbulerU Date '
t5form4.doc 06/03 System Pumping Record•Page 1 of 1