HomeMy WebLinkAboutSeptic Pumping Slip - 953 JOHNSON STREET 11/4/2016 : Commonwealth of Massachusetts RECEIVED
City/Town of .
ug S stem P�umping.Record ° 1
Farm 4
F�EAL H jai:PAR r OENT
DEP has provided this farm 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, Left]Right rear of house, Left/ #side of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name.
Address(if different from location)
City/Town ' State- i d
Telephone Number
i
B. Pgmping Record �
1. Date of Pumping Date 2. auanti Pumped: Gallons
3. Type-of system; ❑ Cesspool(s) ❑• eptic Tank ❑ Tight Tank t.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No,
' S. Condition of System: _ C
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises inc-
Company
7. Locati,n_w,ere contents-were disposed:
'.L Lowell Waste Water
SA gz6z
SignAu.te ct HauleV Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1
