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HomeMy WebLinkAboutSeptic Pumping Slip - 100 JOHNNY CAKE STREET 11/8/2016 Commonwealth of Massachusetts City/Town of . RECEIVED System Pumping-Record NOY I ��tlld:a Form 4 HEAL'i'H DE�i��IR ���:NT DEP has provided this form for 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 I. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address I 6 , city/Town State Zip Code 2. System Owner. Name' Address(if different from location) Cityrrown ' State Zip Code ; Telephone Number i .B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons c� 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Fitter present? ❑ Yes o If yes, was It cleaned? ❑ Yes © No, 5. Condition of System: a 6. System Pumped By: Nell.Batesan " F5821 Name Vehicle License Number Bateson Enterprises Ina Company 7. Lo tipa urge a contents were disposed: G L S: Lowell Waste Water Sign a Haule Date t5form4.doc•08/03 System Pumping Record•Page 1 of 1