HomeMy WebLinkAboutSeptic Pumping Slip - 91 JOHNNY CAKE STREET 8/16/2016 Commonwealth of Massachusetts
City/Town of r .E
M Syi tern Pumping-Record
Form 4
TOM OF
11,DEP has provided this form for use-by local Boards of Health. Other forms may be�u , Out 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 forrh 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 i 6it front of hou, , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left Rigit font"of building, Left/Right rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner:
Name.
Address(if different from location)
City/1 own ` State Zi code
Telephone Number }
.B. Pumping R�?cord
1. Date of Pumping Date 2. Quantity Pumped: Gallons"`
3. T yp e-of s y stem: Cesspool(s) [0-septic Tank Tight Tank i.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E3,lgo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: c
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locationtents were disposed:
GL.Q ec Lowell Waste Water
Sign WHtaiule Date
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