HomeMy WebLinkAboutSeptic Pumping Slip - 826 JOHNSON STREET 10/19/2016 Common wealth of Massachusetts
n. City/Town of
( /t
System Pumping-Record
Form 4 T
DEP has provided this farm for use=by local Boards of Health. Other forms may be'used, but'thfe
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/Right rear of housLef lig �si`de o haus Left 1
t
Right side of building, Left/Right front of building, Left A Right rear of building, Unddec
Address 1.-- IT...
CiWTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown ' State Zip Code
• ` Telephone Num�ber � . ...�..�_�,°^•. .f�
j
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ® Septi ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q--Na- If yes, was it cleaned? ❑ Yes ❑ No
Condition of System:
6.• System Pumped By:
(Veil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, Locatia heje contents were disposed:
G Ltt''S: 11 Lowell Waste Water
SignAtufe Houle Date
t5form4.doc•08/08 System Pumping Record•Page 1 of 1