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HomeMy WebLinkAboutSeptic Pumping Slip - 150 JOHNNY CAKE STREET 9/27/2016 Commonwealth of Massachusetts City/Town of System Pumping_Record Eata ! j{,l�ta rr Form 4 ©EP has provided this form for useFby 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, Left/<Le rear of h s , Left/right side of house, Left/ Right side of building, Left/Right front of building, g rear of building, Under deck Address CitylTown State Zip Code 2'. System Owner: Name. Address(if different from location) CitylTown State- �b' Zi de Telephone Number r ; f .B. Pumping_ Record . 1. Date of Pumping mate 2• Quantity-Pumped: Gallons 3. Type-of system: © Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? No If yes, was it cleaned? es ❑ No, 5. Condition of System: 6; System Pumped By. Nell.Bates*on F5821 j Name Vehicle License Number Bateson Enterprises Inc Company j 7. L71, G>1A� Te contents-were disposed: �S: Lowell Waste Water W10AF Sign a qt 1-18ule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1