HomeMy WebLinkAboutSeptic Pumping Slip - 970 JOHNSON STREET 9/14/2016 Commonwealth of Massachusetts ;V.
City/Town of
System Pumping-Record
- Form 4
b• ,
DEP has provided this form far 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 house, LeW1 t_t of h
gus
, Left/right side of house, Left/
+ Right side of building, Left/Right front of building, cleft/Right rear of building, Under deck
Address
city/town State Zip Code
2. System Owner.
Name.
Address(if different from location)
City/Town State.
Telephone Number
.B. Pumping flecord
1. Date of Pumping Hate 2. Quantity Pumped: Gallons i
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes { o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo do ere contents-were disposed:
G L S'. Lowell Waste Water
,m
/
Sign a I HaulerU Date
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