HomeMy WebLinkAboutSeptic Pumping Slip - 767 JOHNSON STREET 7/31/2017Cornmonwealth of Massachusetts
City/Town of.
System Pumping Record
.3 Z017
Form 4
DEP has provided this form for usety local Boards Of Health. Other foIrm°V4t4s-m°aFyI4b°R;u14sAeldc)°, butthe
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 PumpingEALRTHecoErdP"'RmTuMsEtt4bTe 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 / rigrde oft -louse; Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Uncle -Heck
City/Town
2. System Owner:
Addre
(if diffe
nt from location)
City/Town '
State.
Telephone Number
Zip Code
(
B. Pumping Record
Date of Pumping
3. Type.of system':
Other (describe):
Date
Cesspool(s)
2. Quantity, Pumped:
El -Septic Tank 0 Tight Tank
(
Gallons
.••••••-
4. Effluent Tee Filter present? 0 Yep
' 5. Condition of Syste •
If yes, was it cleaned? 0 Yes ID No,
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L S Lowell Waste Water
F5821
Vehicle License Number
Sign e Haul- Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1