HomeMy WebLinkAboutSeptic Pumping Slip - 707 JOHNSON STREET 9/11/2017 Commonwealth of Massachusetts RECEIVED
C4/Town ofSEP �j 12017
.
w° System Pumping.record
V.
PQrm 4 HMTK DEMRIMENT j
DEP has provided this form for use-by local Boards of Health. Other farms 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. 1
A. Facility Information 1
1. 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 df building, Under deck
Address
citylrown State - Zip Code
2. System Owner
Noma'
Address(if different from location)
Citylrown State ` ..ZIR
Cod
f Telephone Number
Pumping Record �.
1. Cate of PumpingDate 2• Quantity Pumped:
Gallons �
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
Bateson Enterprises Inc-
Company
7. Locati are contents-were disposed: t
t
LS-QLS-Q Lowell Waste Water {
. F
Signitute cf Haule Date
k5form4.doc 06/03 System Pumping Record•Page 1 of 1