HomeMy WebLinkAboutSeptic Pumping Slip - 719 JOHNSON STREET 9/7/2016 IRECEIVED
I
Commonwealth of Massachusetts .
City/Town of ��� �e
���i�.OWN Off'
System Pumping.Record HiA,.iH Hr
Form 4
DEP has provided this farm for use>by local Boards of Health. other forms maybe•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
I. System Location: Left/Right front of house, Left/Right rear of house, Left/ t is d hour, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Un er eck
Address � -®--- (
CitylTown State Zip Code
2. system Owner.
Name`
Address(if different from location)
CityfTown ' Stat Z' � �
Telephone Number
i
t,
.B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped: ---
Gallons
3.
Type-of system. ❑ Cesspool(s) ED-Sep-tic Tank ❑ Tight Tank i
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes ®*too If yes,was it cleaned? ❑ Yes ❑ No
5. Condition m:of.Syst
(�6,;,� l
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatioq vh`er contents were disposed:
.L S: Lowell Waste Water /y\'
. FOA
Signitu fe cf Haule Date
t5formCdoo•06103 System Pumping Record*Page 1 of 1