HomeMy WebLinkAboutSeptic Pumping Slip - 851 JOHNSON STREET 6/1/2017 Commonwealth of Mh u
Cit�/Town of
SyMem Pumping.
Fo � i ?1
DEP has provided this form for use>by local Boards of Health. Other forms maybe 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 W
the local Board of Health or Other approving authority.
A. Facloty. Information
1. System Location: Left/Right front of Hous e /' igh r of h , Left/right side of house, Left I
sx^N Right side of building, Left/Right front of bui ng, Left/Right rear of building, Under depk
cftyfTown State Zip code "
2. System Owner:
Name'
Address(if different from location)
City/Town stag� � .w..C �� A C
Telephone Number
B.
Pumping Recr
c0
1. Date of Pumping oa 2, Quntity Pumped:
gallons "
. Type-of system: Ll Cesspool(s) ptic`dank El Tight Tank
Other(describe):
Q. Effluent Tee Filter present? [I Yep Ewo, if yes,was it cleaned? 0 Yes E' No,
5. Condition of System: / f�
6: System Pumped 6y:
Nell.Sat 'on P6821
Name Vehicle License Number
Bateson htertorises Inc'
Company
7, Lo tion. contents-were disposed.
Lowell Waste Water
sign a Mal Date
t5fbrm4.docm 06/03 system Pumping Record Page 1 of 1