HomeMy WebLinkAboutSeptic Pumping Slip - 889 JOHNSON STREET 6/15/2017 Commonwealth of Massachusetts
Oty/Town of .
System Pumping-Record
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DEP has provided this form fo•r use-by local Boards of,Health. Other forms may'be'used, but the t
Information,must be substantially the same as that provided here. Before using.this form., '
heck with your 1
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 Locatio Le' high t o Hous , Left I Right rear of house, Left/right side of house, Left I
Right side of bu . ' g, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
Z. System Owner.
Name'
t
Address(if different from location)
Cityrrown ' State Zi Code
- f
Telephone Number
t
.B. Pumping Record
1. Date of Pumping ante 2• Quantity Pumped:
Gallons
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3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank ,.
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number t
Bateson Enterprises lnc�
Company
7. LocarL
where contents-were disposed:
GS: Lowell Waste Water
�a SA.
Sign t e I Hiaule Date f
5form4.doc-06/03 System Pumping Record•Page 1 of 1
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